Inspection on 15/05/06 for Maple Grove Hostel

This inspection was carried out on 15th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Maple Grove Hostel 15/05/07

Maple Grove Hostel 12/12/05

Maple Grove Hostel 16/06/05

Maple Grove Hostel 24/11/04

Maple Grove Hostel 28/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Maple Grove Hostel 25-27 Maple Grove Bath Bath & N E Somerset BA2 3AF Lead Inspector David Smith Key Unannounced Inspection 15th May 2006 09:45 Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Maple Grove Hostel Address 25-27 Maple Grove Bath Bath & N E Somerset BA2 3AF 01225 420548 01225 420548 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Bath & North East Somerset Council Mrs Ruth Theresa Rowsell Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2005 Brief Description of the Service: Maple Grove is a Local Authority residential care home for up to ten adults who have a Learning Disability. The home is situated in a quiet location, which provides easy access to local shops on Bear Flat and Moorland Road, Bath. The city centre is approximately one mile away. Maple Grove is two spacious semi detached Victorian houses, which have been connected to form one building. The home has large gardens to both the front and rear of the properties. There are ten single bedrooms, one of which is used to provide respite care to people living in the community, two communal lounges, one dining room, two bathrooms without toilets, one shower room with toilet and two separate toilets. Three of the bedrooms have en-suite facilities. The home does not have adapted bathing facilities or lift between floors. The home is therefore not suitable for people with poor mobility. Support is also provided to four people living in their own flats in the local community and seven people who regularly use the home’s respite service. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection carried out over one day. The inspector gathered information for this report from discussions with the manager, staff members and service users. Interaction and communication between staff and service users was also observed. Care plans and associated records, menus, staff personnel files, staff training files and health and safety records were examined. The inspector was also provided with a tour of the home. What the service does well: The service remains focused on the people who live in the home. The use of person centred planning tools is prominent. This ensures each service user is supported to determine their own service. Maple Grove will be subject to future reprovision. The staff team have continued to ensure that all service users have been actively involved in these discussions. Service users’ families and friends views are encouraged and they are welcomed to act as advocates. There is a strong core of committed staff who are focussed on their responsibilities. Staff are well supported by a manager who is dedicated and able. Staff are responsive to each service user’s needs. The home actively seeks support from other professionals to help improve the quality of the service it provides to each person. There is an effective quality assurance system in place. This ensures that the home is able to review its service and improve where possible. Maple Grove offers clean, pleasant and homely accommodation with good quality furniture, fixtures and fittings. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The home should consider developing accessible Service Users Guides for each person who uses the service. The Quality Assurance Guide should be amended to refer to the Commission for Social Care Inspection rather than the National Care Standards Commission. This will ensure all readers of this document are provided with up to date information. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. The quality in this outcome area is good. Service users are given the information they need about the home to enable them to make an informed choice. This should be adapted into an accessible format for each service user. Service user support is based upon an individual assessment of their needs and the transition to the home is well managed by the team. Each service user has a statement of terms and conditions with the home. EVIDENCE: The home has a comprehensive Statement of Purpose. This was last updated in May 2006. Each service user also has their own guide to the service. The home is currently trying to adapt these into a more accessible format for each service user. This is certainly in accordance with the person centred philosophy of the home and would help to improve access to information for a number of people who use the service. Both documents detail the facilities, services and ethos of the home. These have been amended to advise readers that CSCI inspection reports can be accessed via CSCI either by telephone or by accessing the website. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 10 The care records examined show that each service user had comprehensive assessments carried out prior to using this service. Information from a range of health care professionals had been provided and information from families/carers had been sourced where appropriate. Each person’s transition into the home is managed in a person centred way. This process is determined through discussion with the service user, their family, funding authority and the home’s staff team. Each service user is provided with a house contract. This contract describes each person’s rights and responsibilities whilst living in the home. This document is signed by each service user and the home’s manager. This is good practice. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. The quality in this outcome area is excellent. Comprehensive care plans are in place that identify service users’ assessed needs and personal goals. These are regularly reviewed. Maple Grove provides a service focused on the people who live in the home. Service users make decisions about their lives and are given assistance as and when needed. Service users are consulted on, and participate in, all aspects of life in the home. The Risk Assessment process supports each service user to take risks. These are now reviewed and updated regularly. Each service user is assured that information about them remains confidential and is stored securely. EVIDENCE: Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 12 Four service user care plans were examined in detail and these provided comprehensive information on the areas of support each person required. The home has adapted some information within the care plans into a format which each service user can access. For example one service user has a visual communication book. This contains picture symbols for a wide variety of topics this person may want to discuss. Another care plan contained several photographs of the service user, which visually describe the support required with certain tasks. Regular reviews are held, which include service users, their families, Social Workers and Keyworkers. These are clearly recorded and the outcomes used to update individual care plans. The home has improved its review process as it now encourages pre-review meetings with service users. This process is designed to prepare service users for and to encourage their involvement in each review. The topics each service user wished to discuss were recorded and raised at the review meeting. The record of each review meeting confirmed this. The last review for each person used a person centred planning style known as a path. This process focuses on the dreams/wishes of each person and then uses a staged approach to work towards these. These contained both written and pictorial information. The progress of individuals working towards their goals is monitored closely by each person’s keyworker. Service users have each kept their path and many are displayed on their bedroom walls. Several service users showed these to the inspector and explained what these meant to them. Interactions between staff and service users were observed at various times during the inspection. These demonstrated the staff had a good knowledge of the support needs of service users and how to communicate effectively. Discussion between the inspector, the manager and staff members also confirmed this. There are regular service user house meetings, the last of which was held on 1/3/06. The records of these meetings show that a wide variety of topics are discussed. The views of service users are taken seriously and acted upon where possible. There are both generic and person centred Risk Assessments in place. These support service users to take risks as part of an independent lifestyle. These form part of each persons care plan and are now regularly reviewed and updated. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 13 Each service user has a document which describes the right of access to their personal records, which forms part of their care plan. This ensures confidentiality is promoted and explained to each service user. All records relating to service users are stored securely in the main office. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. The quality in this outcome area is good. Service users are encouraged and supported to take part in appropriate leisure activities and training sessions. Service users are supported by staff to use community facilities, enjoy holidays and visit families and friends. Person centred planning remains prominent in the service. This enables service users to participate in a wide range of activities and supports each person to develop their own service. The home offers a wide choice of a well-balanced and healthy menu. EVIDENCE: Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 15 The home has a person centred approach in supporting each service user to develop. The records maintained within the home enable each persons progress to be assessed and the support provided adapted accordingly. Service users have their own timetable of activities. This includes regular access to local community facilities such as shops, cinema, pubs, local church groups as well as Local Authority Day Services. It was evident that several service users had made significant progress since moving into the home. Some were attending more varied day services or longer sessions. Others were accessing the community independently. The home is also supportive of work placements in the local community and is actively working towards this goal with some service users. Staff spoken with explained that they work hard to ensure each person is provided with opportunities to do things which they enjoy. Each person is seen as an individual and is respected as such. Each service user has a key to their bedroom and during the inspection there was evidence to suggest that staff respect the privacy of those who live in the home. Service users are supported to maintain close contact with their families and friends. Some regularly visit their families, enjoy weekend stays and visitors are welcomed to the home. One service user told the inspector they had recently been on holiday to Torquay. They chose to travel by train and stayed in a hotel. Staff members had supported them to organise this trip and accompanied them. Each service user has access to the kitchen where they can prepare their own drinks, snacks and meals. Staff confirmed they offer the support appropriate for each person. Weekly menus are planed in consultation with the service users. These show a wide range of food, which provide both a healthy and balanced diet. Service users likes, dislikes and allergies in relation to food are known and clearly recorded. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. The quality in this outcome area is good. The care plans clearly explain the support each service users requires in relation to their personal and health care. Experienced staff have a good knowledge of each service user and how to provide appropriate levels of support. A monitored dosage system of medication for service users is in operation and this is well managed. EVIDENCE: The care documentation in place for service users provided clear guidance for staff on how they should support those living at the home with their personal care. The care plans examined showed that service users were registered with a local GP, dentist, optician and chiropodist. Other specialist services are accessed when an identified need arises. These are provided by Bridges Community Learning Disability Team. Care records show the home is regularly supported by the Consultant Psychiatrist, Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 17 Physiotherapists, Speech and Language Therapists, Occupational Therapists and other relevant health care professionals. Contact with each professional is recorded and forms part of each persons care plan. There is a core of experienced staff who have a good knowledge of service users healthcare needs. Any changes, which may cause staff concern, are noted and acted upon. It was evident at this inspection that the management and staff spoken with are sensitive to the personal/healthcare and emotional needs of those using the service. The home uses the Boots Monitored Dosage System of medicine administration. This system is well managed. The medication administration file contains details of each service users GP, a photograph of service users, profiles of prescribed medication, guidance on expiry dates of medication and information relating to returning medication. Each service user medication record was correctly completed, signed by staff with no gaps evident in the records. Staff records examined show that they have received medication training, ‘Protocol Training’, which is accredited by the City of Bath College. This is in the style of an NVQ unit and contains four elements; introduction to medicines, care workers role, administration and medicines of differing client groups. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The quality in this outcome area is good. The complaints policy and procedure is robust, clear and effective and there is every indication that service users feel their views are listened to and acted on. The staff team are provided with training and support to ensure the welfare and safety of service users. EVIDENCE: Each service user has their own complaints procedure. This is available in both written form and on audiotape. Families are also provided with a copy of the home’s complaints procedure. There have been no complaints recorded since the last inspection. Several generic Local Authority complaints leaflets supplement these and it also has a confidential reporting policy if staff have any concerns regarding the service they work in. Bath and North East Somerset has a policy relating to Control and Restraint and an inter agency procedure on the Protection of Vulnerable Adults which are both available within the home, as is The Department of Health’s ‘No Secrets’ guidance. The home has developed its own Protection of Vulnerable Adults policy, which gives clear, concise information and instructions to staff members if they witness or suspect abuse. This was last updated in May 2006. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 19 Staff are provided with training in relation to the Protection of Vulnerable Adults and are subject to Criminal Record Bureau enhanced disclosures. The home maintains records of accidents and incidents. It has also provided relevant reports to the Commission in accordance with Regulation 37. It was noted by the inspector that the home has received several letters from families which were extremely complimentary regarding the service their relative had received and about the home and staff team more generally. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30. The quality in this outcome area is good. Service users live in a homely, comfortable and safe environment, which is also clean and hygienic. Each person has decorated and furnished their bedrooms to suit their individual tastes and needs. Several areas of the home have been redecorated which has improved the environment for service users. EVIDENCE: Maple Grove is formed by two semi detached Victorian houses, which together provide spacious and comfortable accommodation for service users. There are large gardens to both the front and rear of the properties. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 21 The inspector did view all of the communal areas of the home and was invited by four service users to view their bedrooms. All areas of the home were clean and tidy on the day of inspection. All furnishings and fittings are of a good quality. The house is tastefully decorated and there are many photographs of service users displayed, which help to personalise the home. Each bedroom viewed has been decorated and furnished by the service user to make it personal to them. Several areas of the home have been recently redecorated and new pictures have been fixed to the walls. The manager told the inspector that service users had chosen both the colour schemes and the pictures and that they had really enjoyed being involved in this process. This redecoration has greatly improved the appearance of these areas. All maintenance and refurbishment work is reported to the Local Authority Property Services Department who approve and organise work required. This department carried out a ‘Condition Survey’ on the home in December 2005. This report described the planned maintenance in both internal and external areas of the home for the 2005-2010 period. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. The quality in this outcome area is good. Service users are supported by an experienced staff team who have a good knowledge of their support needs. The home has an effective staff team which support the service users needs at all times. The home’s recruitment policy promotes both individual’s rights and their safety. The training programmes ensure that all staff are provided with the guidance and skills to provide support to each service user. All staff are now supervised on a regular basis. The collation and storage of staff files has been signicantly improved. EVIDENCE: Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 23 There is a core of well-established staff with varying skills and abilities who meet the needs of each individual who uses the service. Staff were observed interacting well with service users and those spoken to demonstrated a good understanding of the support needs of each person in the home. Each staff member spoke positively of the proposed reprovision of the service and confirmed that service users wishes and needs were central to these plans. The staff team meets regularly. All meetings are recorded and appropriate subjects are discussed in order to guide and direct staff practice. The inspector was invited to attend the team meeting held on the day of inspection and did attend part of this. Morale within the team appears to be very good and the manger is planning another team day to build upon and develop this further. The home operates a robust recruitment process and the records examined included application forms, induction checklists, training records and Enhanced CRB Disclosures. The home currently has a vacancy in the staff team. The recruitment process is in hand; applicants have been shorlisted and an interview date set. It is therefore anticipated that this vacancy will be filled shortly. Staff are provided with a variety of training opportunities. Training is provided either by the organisation or external training providers. The staff training records have been significantly improved since the last inspection. A staff-training matrix is in use and this is regularly updated. Each staff member also has an annual training plan. This details the proposed training, together with planned dates. These improved records show that staff are being provided with all mandatory training and additional courses to ensure they have the appropriate skills and abilities to support service users. Fire safety training was held on the day of inspection and all staff are currently working through the Protocol Infection Control modules. The home has made significant progress in supporting staff to gain a National Vocational Qualifications. Three staff have recently completed their qualifications and two more staff have now commenced their awards. An external assessor currently supports the home and the manager is also working towards her NVQ Assessors Award. Regular formal supervision is now provided for all staff. Both the manager and her deputy supervise staff. Records examined show that staff are supervised every four weeks and a clear record of each meeting is maintained, which is signed by both parties. Staff are also appraised on an annual basis, described Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 24 by the home as a ‘Performance Review’. The supervision and appraisal of staff shows a significant improvement since the last inspection. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 and 43. The quality in this outcome area is good. The home is very well run and has effective procedures in place to provide service users with the support they require to lead fulfilling lives. The manager is qualified and competent to run Maple Grove, and meet its statement of purpose, aims & objectives. The manager promotes a person centred approach and this is clearly communicated throughout the service. The views of service users are actively being sought in relation to the reprovision of the service. The health, safety and welfare of the service users is promoted and protected. EVIDENCE: Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 26 The Registered Manager has completed both NVQ Level 4 in Care and the Registered Managers Award. She is currently working towards her A1 NVQ Assessors Award. She also undertakes periodic training to maintain her knowledge and update her skills and level of competence. The management approach is open and positive, with a clear sense of direction and leadership. The ethos of the service is person centred with evidence of relevant tools such as paths and essential lifestyle planning in use. Staff spoken with said their views are listened to, and that they are well supported by the manager. Through discussion with the Registered Manager, staff members and service users it was evident there continues to be an inclusive atmosphere within the home. The service users remain the focus of the service and the Registered Manager is clearly leading and developing the person centred approaches. There have been significant improvements in management systems and structures since the last inspection. It was evident that the manager had worked hard to address all of the requirements and recommendations in the last inspection report. The service user involvement in the reprovision of the service remains central to this planning process. Each person’s path makes reference to the plans to move into new accommodation and how this is to be supported/achieved. Family consultation meetings have been held and the home is using Paradigm’s ‘Standards in Supported Living’ to guide their practice. The manager told the inspector that the home had recently won an award for their work in this area. The home has its own Quality Assurance guide. This describes the service values, principles and goals and how these are to be achieved. All staff have signed to say they agree with these principles. This document requires minor amendment as it refers readers to the National Care Standards Commission rather than the Commission for Social Care Inspection. The registered provider’s representative makes regular visits to the home, and produces a comprehensive report of her findings, which is send to the Commission on a monthly basis. There are recording systems in place to support Health and Safety within the home, which are being used consistently. Records examined included fire drills, fire alarm system checks, fire fighting equipment checks, water temperature checks, COSHH products, risk assessments, PAT testing and fridge/freezer temperature recording. All of these records were in order and checks were up to date. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 27 Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 4 X X 3 3 Version 5.1 Page 29 Maple Grove Hostel DS0000038861.V293559.R01.S.doc Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA39 Good Practice Recommendations The Service User Guides should be developed in accessible formats. The Quality Assurance Guide should be amended to include the Commission for Social Care Inspection. Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Maple Grove Hostel DS0000038861.V293559.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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