Inspection on 09/08/07 for Maria Skobtsova House

This inspection was carried out on 9th August 2007.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 27 Houndiscombe Road Mutley Plymouth Devon PL4 6HG Lead Inspector Megan Walker Unannounced Inspection 9 August 2007 11:00 th 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 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 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 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. 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 27 Houndiscombe Road Address Mutley Plymouth Devon PL4 6HG 01752 221328 01752 225988 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) Maria Skobtsova House Limited ****Post Vacant**** Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can also accommodate service users with a mental disorder and additional physical disabilities up to 65 years old. The home may accommodate 1 service user named elsewhere with a mental disorder and additional learning disability. New Service Date of last inspection Brief Description of the Service: Maria Skobtsova House Limited is a care home providing accommodation and personal care for up to eight people aged 18 - 65, with various mental disorders, some of whom may have a physical disability. Emergency admissions are not accepted nor is intermediate care provided. The home is not registered to provide nursing care. Maria Skobtsova House Limited was registered with the Commission for Social Care Inspection (CSCI) in January 2007. It is owned and administered by Maria Skobtsova House Ltd, however the senior management team is shared with its sister organisation, The Community of St Anthony and St Elias, a private sector organisation owning several other care homes in Devon. The care home is a three storey mid-terraced house located in the residential area of Mutley in Plymouth. All the homes bedrooms are single and are on the lower ground and 1st floors. They all have en suite toilets and some have en suite showers or baths. On the ground floor there is a large kitchen/diner, two lounge rooms with one of them including a dining area, and an arts/crafts room. The facilities include a shaft lift, and the house has some adaptations for people with physical disabilities. The home has front and back gardens with a patio, grass and flowerbeds and all areas are accessible to the people living at the home. There is private parking at the rear of the property and on street parking (pay meter) is available at the front. A full range of amenities and facilities are within walking distance of the home, including bus routes and Plymouth railway station. At the time of this inspection the fees ranged from £1568.36 to £2150.00 per week according to individual assessment of care needs. These fees do not include toiletries, clothes and other personal purchases. 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key Inspection. The fieldwork part of this inspection was unannounced and took place on Thursday 9th August 2007 between 11h00 and 16h45. This visit included talking to people who live at the home and staff that work there, and observation of interactions between them. There was also a tour of the premises, and inspection of care plans, staff files, medication and other records and documentation. The House Manager of Maria Skobstova House Ltd is awaiting a decision to become the Registered Manager of the home. Both he and the Assistant Manager were able to provide relevant information such as the day-to-day routines as well as the management of the home for the purposes of this inspection. In addition other information used to inform this inspection: • The Annual Quality Assurance Assessment (AQAA) completed by the House Manager • All information relating to Maria Skobstova House Limited received by the CSCI since it was registered with CSCI in January 2007. 22 Cards and Surveys sent out, the CSCI received back – • 0 People who use this service “Have Your Say About Maria Skobstova House Limited ” Care Homes Surveys • 2 “Relatives/Visitors” Comment Cards • 3 Care Workers Surveys • 0 General Practitioner (G.P.) • 2 Health/Social Care Professional in contact with the home 1 requirement and 2 “Good Practice” recommendations were made as a consequence of this inspection. What the service does well: What has improved since the last inspection? What they could do better: 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 6 In spite of a discussion earlier this year with the Registered Provider about the organisation’s arrangements for access to personnel information, and how this could be modified to improve for inspections, staff files were not available at the care home at the time of this visit. The information brought to the home from the organisation’s Head Office for inspection purposes did not provide evidence of a clear recruitment process and relevant training that meets the requirements of regulation to ensure the safety of the people using this service. 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. The summary of this inspection report can be made available in other formats on request. 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 7 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 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4, 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents can feel confident that their needs will be assessed before moving into the home and that they can have the information they need to make an informed choice about the home. EVIDENCE: Anyone considering moving to Maria Skobstova House Limited receives a thorough assessment of their care needs before they are offered a place. The House Manager explained that generally he would visit the person at their place of residence. This was an assessment and an opportunity for the person to learn more about Maria Skobstova House Limited. The person would be invited to visit the home, gradually building on a short day visit to an overnight stay. These visits would be tailor made to suit the person so they could benefit from time spent at the home and make an informed choice about moving there. The care files that were inspected each had a copy of a contract however these were not signed. The House Manager said that the signed original was kept on 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 9 another care file held in the Head Office. The contract and terms and conditions of residence had not all been updated to show the change of ownership of the service, i.e. Maria Skobstova House Limited. 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are involved in their individual plan of care and are supported and encouraged in all aspects of their lives. EVIDENCE: The people living at Maria Skobstova House Limited were supported and encouraged to manage their own daily routines and personal decision-making within any necessary risk assessed restrictions. Care plans inspected were thorough in identifying individual needs and how these could be met. Each person had signed his care plan and the reviews of his plan. Reviews were held on a regular basis. At the time of this visit it was an all male household however the home is registered to provide care for women too. 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use this service have a variety of opportunities for personal development as well as appropriate leisure activities. EVIDENCE: On the day of this visit people living in the home were in and out as they went about their day. This included, for example, Italian lessons to prepare for a forthcoming trip to Sicily, and a karaoke session at a local pub. There was evidence seen on care files that people used local amenities and were accompanied by staff often on a one to one basis. People also had access to local day services if this was an agreed part of their care plan. The home had a room specifically designated for arts and crafts. The Assistant Manager explained that recently a specialist instructor had come to the home to teach people how to make lanterns. Evidence of these lanterns was seen around the 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 12 home. Staff had use of a car belonging to the organisation that they could use to transport people living at the home when necessary, although those who are able are encouraged to use public transport. Everyone was encouraged to participate in all the domestic activities in the home. Contact with family and friends was dependent on individual preference and circumstances. For some people it was telephone contact whilst others went for short stays at their family home. Care plans and reviews showed support and guidance, when needed, given to assist people in meeting new people and working towards friendships and/or more intimate relationships. A resident who was asked about food provided for him, said that generally he was content. He could choose what he ate, and he knew what he couldn’t eat for health reasons. Inspection of care plans found that they clearly stated dietary needs. The meals are planned at the beginning of each staff shift. The staff decide with people living in the home their preferences for meals over the forty-eight hour period of the shift. The Assistant Manager explained that there was an opportunity for “Take Away” meals to be a weekly option on the menu. Inspection of the Meal Planning/Meal Preparation sheet completed by the staff each shift showed who was involved in planning each meal, who was involved in preparing each meal, the food eaten, and who ate when and where. It was evident from these that people could be involved in any/all aspects of each meal from planning to preparation. Everyone is encouraged to eat together however arrangements to eat elsewhere in the house are made if anyone needs this. The meals recorded were varied although some staff members were vague in recording what was actually eaten, for example, lunchtime recorded “Brunch” followed by the evening meal as “sandwiches”. When asked if the type of meals prepared were dependent on individual staff cooking capabilities and confidence in preparing meals for a group of people, the Assistant Manager was positive and praised the culinary skills of the staff team. All staff undertake basic food hygeine training and later this month some staff were due to start a “Safer Food, Better Business” training session to comply with the Food Standards Agency regulations and recommendations. 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: At the time of this visit everyone living at the home was independent with his personal care. Staff gender and preference was not, therefore, recorded on care plans. Information sheets were seen on individual care files about specific illnesses and conditions, and how to manage it. Some of this information the House Manager had downloaded from the Internet. Healthcare professionals working with people living at the home had provided other information. It was comprehensive and the House Manager confirmed that staff had access to this and were encouraged to read it. He also acknowledged that the care needs of the people living in the home were wide ranging and at times this could be challenging for staff. Because of this staff often worked on a one to one basis 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 14 with the people living in the home, to try and ensure personal and emotional needs were met. Medication was seen stored in a lockable metal locker cupboard in the staff room. This room was kept locked when not in use. One member of staff designated each day, had responsibility for medication. Those people living in the home who required medication received it according to the dosage at required times. They were expected to come to the staff office to receive and take it. Medication records were seen and these were dated and signed by a staff member when given. Medication was checked against these records and this too was correct. No one at the time of this visit was self-medicating. Anyone going away or out for the day would be given their medication to take with them. The medication records were signed to indicate this. On return from a short stay away any surplus medication would be checked and recorded as returned (or not if this was the case). 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use this service are able to express their concerns and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: Neither the home nor the CSCI have received any complaints regarding the service since its registration earlier this year. It was evident from inspection of care plans and daily logs that people living in the home were able to express their concerns to the staff. Talking to staff members it was evident that issues were more likely to be dealt with as they arose and if necessary other agencies or senior staff in the organisation would be consulted. A member of the senior management team visits the house regularly, and this offers an opportunity for people to talk about any particular ideas or concerns they may have. The organisation arranges in-house training for all its staff so that they would know how to recognise abuse, neglect and self-harm, and deal with it appropriately. All staff had recently or will shortly be taking a training course on the Mental Capacity Act, its implications for this service and how they can implement the act for the benefits of the people using the service. 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 16 There were clear instructions on care plans about exceptional circumstances when it would be relevant to use physical restraint as a final measure to protect people using this service. The CSCI has been notified after any event that required physical intervention and restraint by staff. 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use this service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The home was comfortable, safe, clean and well maintained. People living at the home had use of two lounges, one of which was used as a quiet room and for meeting with visitors in private. The kitchen was large, light and airy with a large dining table and chairs. In addition to these communal rooms, there was a room designated for arts and crafts. There was a laundry room on the lower ground floor for use by the people living in the house. Most of the rooms were decorated to a good standard although a couple of empty bedrooms were looking tired and the carpets were stained and grubby. 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 18 It was evident that people felt ‘at home’ in the house and during this visit they were seen using all the communal areas. Each person had a single bedroom on either the lower ground or first floors. All the bedrooms had en-suite toilets, three also had en-suite showers and one had an en-suite bath. The bedrooms reflected personalities and were individual in style. Each room had a suitable lock so that its occupant could lock their door if they wished. Staff could override these locks in the event of an emergency. Someone living in the house confirmed that he was happy with his room, it was comfortable and he liked his bed. In addition to the en-suite facilities, the home had a bathroom with a bath, over bath shower and was hand basin on the lower ground floor; a toilet and wash hand basin on the ground floor; and on the 1st floor, a shower and wash hand basin and a bathroom with a bath, over bath shower, toilet and sink. At the time of this visit staff used the bathroom on the lower ground floor. All the bathroom and toilet doors were also fitted with suitable locks that could be opened from the outside in an emergency. The home has been adapted to accommodate people with physical disabilities. This included ramping, a shaft lift, a bath hoist in an en-suite bathroom, a high toilet, equipment for lifting and transferring, grab rails and eating aids. The home had a ‘no smoking’ policy within the building however there was a designated smoking area outside at the rear of the house. Garden furniture was provided on the patio and on the grass area. The Assistant Manager said that people could eat out here if they so wished. Anyone living in the house with an interest in gardening was encouraged with this and maintaining the vegetable garden. At the time of this visit staff had use of four bedrooms for night duty and to store personal belongings. There was no lockable storage space available to staff in their rooms and the rooms were not locked. However the House Manager that each staff member would be given the key for their room at the start of their shift hence could choose to lock their room. At the time of inspection, there were only five people living in the home and staff were able to use the vacant bedrooms for ‘sleeping-in’ rooms and/or storage. The Assistant Manager explained that anyone considering moving in to the house would be able to choose which room they preferred from the vacant rooms. 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People are cared for by a competent staff team however the organisation’s arrangement for the storage of staff files impedes the House Manager’s role in ensuring that a robust recruitment process is followed when recruiting staff. EVIDENCE: At the time of this visit the rota showed that five staff were on duty during the day and four slept in. The home does not operate waking night cover. The organisation operated an ‘on call’ system whereby members of the management team were available out of office hours. The House Manager and the Assistant Manager confirmed that individual and collective needs of everyone living in the home were met because there is a core team of staff and a key worker system. Care needs were thereby met in a regular and consistent manner. Some of the feedback from staff and relatives who returned surveys or spoke to us during this visit was contrary to this. Generally, however, the staff team felt that when there were sufficient staff on duty and there were not a lot of planned events (e.g. appointments, day 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 20 centres, joint activities with other houses in the sister organisation), people received a good service that was flexible and met their needs and interests. The majority of the staff team at the time of this visit was male. Inspection of the staff rota showed that there was usually only one female member of staff overnight and at weekends. Female staff had asked for a higher ratio of female staff particularly at weekends as it could be an isolating experience for them working and living in an all male household for forty-eight hours. A male staff member commented during this visit that it could be of benefit to the people using the service if there were more women around the house. Although the Annual Quality Assurance Assessment returned to the CSCI stated that staff files were kept at the home, when inspected this was not the case. The documentation seen during this visit was piecemeal. The House Manager explained that the organisation’s Personnel Manager at the organisation’s Head Office held all the full personnel files including a list of training that staff had done. The Personnel Manager was on annual leave at the time of this visit so it was not possible to arrange for these files to be brought to the home for inspection. This arrangement has been discussed at length with the Responsible Individual on two previous occasions, including access to files in the event of the Personnel Manager being absent from work. Training is provided in-house as well as by external training providers. There was evidence on the staff files seen that staff have completed National Vocational Qualifications in Care. 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People using this service benefit from the ethos, leadership and management of the home because it promotes and protects their health, safety and welfare. EVIDENCE: During this visit the House Manager was found to be approachable. He was keen to promote the welfare and general well being of the people living at the home with no discrimination or pre conceptions. He had applied to the CSCI for registration as the manager of the home and at the time of this visit he was awaiting a decision. He was also waiting to start the Registered Manager’s Award. He was appropriately qualified, competent and experienced for his role as the House Manager of the home. His approach and attitude communicated 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 22 an open, positive and inclusive enthusiasm for everyone in the house. The House Manager’s role is supported by the organisation’s Senior Management Team based at the Head Office in Totnes. For example, the co-ordination of the weekly rota and staff induction and training programmes. On this visit the House Manager said that it would be beneficial to him and the staff if full copies of the personnel files were kept at the home for supervision purposes. Also an up to date copy of training staff had done and what training they needed. A member of the senior management team regularly visits Maria Skobstova House Limited specifically to spend time with the people living there, collectively and individually, seeking their views and opinions about the home. The CSCI receives “Regulation 26” reports (i.e. visits by Registered Provider) from these visits. The CSCI has introduced a legal document called an Annual Quality Assurance Assessment (AQAA). This is an annual report sent to the CSCI by all service providers with information about the provision and quality of their service, and how the people using the service are involved in deciding what and how the service is offered and provided. The AQAA from Maria Skobstova House Limited was completed and returned to the CSCI after an agreed time extension. The CSCI was advised in a separate letter that this had been due to the complex nature of the document. It was noted in a Regulation 26 notification that the House Manager had attended an in-house workshop as a learning aid to assist completing this document. The completed AQAA received by the CSCI was well written, and informative about the service provided at Maria Skobstova House Limited. Referrals to Maria Skobstova House Limited come from all over England. A wide network of social and healthcare workers as well as other referring authorities therefore use the home as part of the plan of care to meet assessed needs of their clients. The House Manager said that surveys had been sent out to these social and healthcare professionals to seek their views about Maria Skobstova House Limited. The Assistant Manager confirmed this and also that the people living in the home had been asked formally for their views and opinions as well as their families and other contacts. Although there was some evidence during this visit that staff had received training for mandatory subjects such as food hygiene, moving and handling, infection control, and health and safety in the workplace there was no evidence to show that all of these subjects were done annually. The residents are responsible for cleaning of some parts of the premises. Chemicals and other hazardous liquids were seen kept in a locked cupboard. All incidents that affect the health, safety and/or well being of people using this service are reported to the CSCI as required by Regulation 37 of the Care Homes Regulations 2001. 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 23 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 “ ” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 3 X 4 4 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 4 28 4 29 4 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 3 3 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 3 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 3 4 3 X X 3 X 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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. 1 Standard YA34 Regulation Sch 2 Sch 4 Requirement The Registered Provider must ensure that copies of information and documentation in respect of people working in the care home specified in Schedule 2 are kept in the care home to meet Schedule 4 requirements for records that must be kept in the care home. Timescale for action 30/09/07 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 YA5 YA33 Good Practice Recommendations Copies of signed contracts should be kept on individual care plans. The staff rota should be drawn up in consultation with the House Manager so that sufficient staff on duty meets collective and individual programmes of care, particularly at busy times. 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 27 Houndiscombe Road DS0000066039.V337105.R01.S.doc Version 5.2 Page 26 - 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. 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