Inspection on 18/01/07 for Marley Grove (6)

This inspection was carried out on 18th January 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marley Grove (6) 07/11/08

Marley Grove (6) 22/11/07

Marley Grove (6) 23/06/06

Marley Grove (6) 08/03/06

Marley Grove (6) 19/12/05

Marley Grove (6) 18/10/04

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

CARE HOME ADULTS 18-65 Marley Grove (6) 6 Marley Grove Crownhill Milton Keynes Bucks MK8 0AT Lead Inspector Barbara Mulligan Unannounced Inspection 18th January 2007 10:30 DS0000015063.V329755.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 DS0000015063.V329755.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. DS0000015063.V329755.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marley Grove (6) Address 6 Marley Grove Crownhill Milton Keynes Bucks MK8 0AT 01908 260005 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) www.macintyrecharity.org MacIntyre Care Mrs Amanda Anstey Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000015063.V329755.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 3 persons with a learning disability. Date of last inspection 23rd June 2006 Brief Description of the Service: Numbers 1 and 15, Baxter Close and 6, Marley Grove are three separately registered services located in Crownhill, Milton Keynes. They form a small service group providing accommodation and support to nine adult service users with learning disabilities. The homes are located within a short walking distance of each other in a small close in an area with reasonably good public transport to the city centre. There is a corner shop at the end of the road. The service is part of the MacIntyre Care organisation, an established provider of care for people with learning disabilities. At the time of the inspection the residents of Baxter Close included two married couples. The group of homes is managed from Marley Grove, which also provides accommodation for three service users requiring higher levels of support. The staff team works as one group, flexibly covering the needs of service users in all the three settings, rather than being specifically allocated to one or another. Together, Marley Grove and Baxter Close aim to enable people with learning disabilities to live as independent lives as possible. Fees range from £24,401.52 per annum to £ 44,110.04, according to information supplied with the previous questionnaire submitted prior to the June 2006 inspection. Items such as toiletries, trips out and sundries would be additional charges to service users. DS0000015063.V329755.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second key inspection of the service since the implementation of IBL2 (Inspecting for Better Lives). The inspection was undertaken on the 18th January 2007 by Barbara Mulligan and Sue Smith (Regulatory Inspectors) over 7 hours. The Manager was available on the day of inspection. The Inspectors used triangulated methodology to complete this inspection, pre-inspection information such as the previous report was used in the planning process to ensure hypotheses were formulated to support the inspector to explore issues of concern and verify practice and service provision. During the inspection a variety of documentation was assessed, which included Careplans, Risk Assessments, Menus, Rota’s, Training records and Recruitment records. An environmental tour took place, with no issues of concern raised. The Inspector identified three Service Users for Case tracking (over the three services), observing these Service Users and their interactions with others including staff at the home, assessing the available information held in the home relating to the care provision, checking this against observed practice. In addition one Inspector spent the day of inspection speaking with service users to gain their views on the service provided. Feedback received during the inspection provided evidence that Service Users and are happy with the care and support offered by the staff, they were complimentary of the friendly, sensitive and respectful approach of the team. The Inspectors observed positive practice throughout the day, finding Marley Grove to be a relaxed and pleasant home. The inspector would like to thank the Service Users and Staff for their hospitality and their support in completing this inspection. What the service does well: Individual Careplans are in place which outline the care needs of service user and the manner they prefer care to be implemented. All service users have risk assessments in place, which enable them to maintain their independence safely. Activities are provided which are both age appropriate and support the service user to be part of the local community. DS0000015063.V329755.R01.S.doc Version 5.2 Page 6 Families and friends are welcomed to the homes of the service users with restrictions in place requested by the service user. Service users are supported to maintain their independence, managing the day to day running of their flats with staff support. The physical and emotional healthcare needs of service users are met with staff support in place should it be required. Robust medication procedures are in place with self-administration policies and guidance to support both staff and service users. The Organisation takes complaints seriously with a comprehensive policy, which is reflective of timescales in place. The home aims to protect the service users through its policies and procedures, which include the protection of vulnerable adults. There is an effective recruitment procedure in place. Training is provided to staff to support their professional development. The home is managed by a suitably qualified and experienced manager. The home has an effective quality assurance system, which ensures the views of service users are obtained and acted upon. The home operates health and safety policies and procedures, which aim to protect service users and staff. Service Users are happy with the care provided and find the staff and management of the home approachable, supportive and friendly when carrying out their duties. What has improved since the last inspection? The individual Careplans are now up-to-date and reflective of review. Individual risk assessments are now reviewed and revised as necessary. Health and medical needs reflected in the Careplan have improved to a good standard. Appropriate guidance for the self-administration of medications is now in place. An accurate log of complaints is now maintained. A full range of recruitment checks is available in the Marley Grove Office. DS0000015063.V329755.R01.S.doc Version 5.2 Page 7 The staffing levels at the home have been reviewed, however further work is required. Regulation 26 monitoring visits are undertaken by the provider with records of these visits open to inspection. All fire prevention systems are up-to-date with all actions from the recent fire authority inspection actioned. What they could do better: 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. DS0000015063.V329755.R01.S.doc Version 5.2 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 DS0000015063.V329755.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users needs are thoroughly assessed prior to admission, ensuring that staff are prepared for admission and have a clear understanding of the service users requirements. EVIDENCE: No new admissions had taken place since the last inspection, or indeed for some time, so direct evidence of the management of new admissions was not available for scrutiny. However discussion with staff and the manager confirmed that any new admissions would receive a full assessment by senior staff before consideration of placement and that introductory visits and overnight stays would take place prior to any final placement decisions. The views of existing service users would be taken into account. The assessment tool is called “Moving into Macintyre Care” and is comprehensive and detailed. Pictures are included alongside written information to enable the potential service users to understand the process. DS0000015063.V329755.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Careplanning documentation has improved and provides staff with the information they need to satisfactorily meet service users needs. Systems are in place to involve service users in decisions about their lives, with assistance and communication support that allows them to influence their lifestyle and how the home is run. Risk assessments are in place, which outline individual vulnerabilities, which contain control measures that enable service users to live their lives as independently as possible. EVIDENCE: The home provides individual plans of care for each service user living at Marley Grove. These plans have recently been modernised to ensure they acknowledge the holistic needs of the service users. These plans are in line with the service users current identified needs. Alongside these plans is a DS0000015063.V329755.R01.S.doc Version 5.2 Page 11 person centred plan, which is formulated by the service user and is a reflection of their wishes, goals and aspirations. The Careplans formulated by the staff are well detailed with good evidence of how service users prefer support to be implemented. Included in the Careplans is sections which identify such things as religious and cultural needs, physical needs, personal care, feelings and emotions, support needed to manage my behaviour, support needed to access the community and learning and day activities. All information contained was of a high standard and aided staff to provide appropriate support. There was good evidence of health screening taking place and how the home supports service users to access health advisors. The home is facing difficulties when accessing equipment to check the weight of service users who are wheelchair bound or unable to fully weight-bare. As this is not an issue solely found at this service it is recommended the Organisation purchase a set of sit on scales, which can be utilised as a resource for all of its services. Service users at Marley Grove have monthly house meetings. Minutes are kept of these that demonstrate how individuals are given the opportunity to make informed decisions about their lives and how choices are made. The key worker is responsible for supporting the service user in achieving the objectives set. Risk assessments are in place for personal care, medical and health support needs, physical support, relationships and emotional support, leisure and transport support, reducing vulnerability whilst accessing the community, scooter risk and stranger danger support. All risk assessments were found to be up to date, signed and dated by the author. The service users at Marley Grove are encouraged to maintain their personal independence as much as possible DS0000015063.V329755.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users can take part in age, peer and culturally appropriate activities, which support and enrich service users social and educational opportunities. Families and friends are welcomed to the individual’s homes with no restrictions unless previously requested by the service user or significant others. The service users at Marley Grove are supported to maintain their levels of independence with staff support available on request. Service Users meals are prepared and cooked by staff with the support of service users in line with their capabilities. The service users at Marley Grove enjoy a varied, appealing and nutritious menu. DS0000015063.V329755.R01.S.doc Version 5.2 Page 13 EVIDENCE: Service Users are supported to take part in a variety of activities both in their home and in the local community. All service users at Marley Grove attend a local day centre. There is good use of community resources with adequate staff support to access these resources. All service users are well supported by the home and Macintyre Care in pursuing appropriate activities. Service Users are supported to maintain contact with their families dependent on their own circumstances and personal wishes. There are no restrictions on visiting times with the Service Users at Marley Grove able to entertain family and friends as they wish. Clear documentation of the changing needs of service users was evident in the Careplans with additional support plans in place. Meals are prepared at Marley Grove by the staff with service users helping with the preparation of meals in line with their capabilities. Menus in place are varied and in line with the likes and dislikes of service users ensuring a nutritious and healthy diet is provided. There are sufficient snacks and drinks offered throughout the day. The kitchen at Marley Grove has been upgraded providing accessibility for service users with wheelchairs with worktops that can be height adjusted to support service users. DS0000015063.V329755.R01.S.doc Version 5.2 Page 14 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. Service Users needs are outlined in their individual plans ensuring the manner in which they are supported and cared for by staff is appropriate and promotes their preferences. The physical and emotional healthcare needs are generally met, however equipment that supports monthly weight monitoring needs to be purchased to ensure the ongoing and changing health care needs of service users is met. The organisation has robust medication procedures in place, which are in line with current guidance and aim to protect the service users of Marley Grove and the Baxter close homes. Self-administration guidelines, which support the service users at 1, 15 and 15a Baxter Close are provided. DS0000015063.V329755.R01.S.doc Version 5.2 Page 15 EVIDENCE: With the updating and modernising of the Careplan format the needs of service users are now sufficiently reflected. Information regarding personal care is recorded in the individual Careplans. Service users have varying degrees of independence with hands on support provided as required, they are also supported to make decisions such as when they like to go to bed, have a bath, have their meals and take part in other activities. The Careplans set out in detail the service users preferred routines, likes and dislikes and partnerships with families and friends. There was good evidence of healthcare screening with evidence of annual health checks, dentist appointments, podiatry, and optician and physiotherapy appointments. The home does need to ensure those service users that are unable to weight bare are provided with sufficient equipment, which will support the home to monitor their weight on a monthly basis. As this is not an issue pertaining only to the service users at Marley Grove and Baxter Close a recommendation is made that the Organisation purchase weight monitoring equipment that can be used by all of its service users. The service users at Marley Grove are supported with their medication with appropriate policies and guidance in place. MAR sheets are maintained for all of the service users, which were found to be appropriately maintained with no gaps evident. There were no out of date medications held in the home with a returns procedure in place. In addition a self-administration policy is in place, which is implemented by trained staff at Marley Grove when supporting the Baxter Close service users. Weekly audits of self-administration MAR sheets and medication stocks are maintained. All completed MAR sheets are then stored in the office of Marley Grove for administration purposes. There were no out of date medications held in any of the service users homes with all medication procedures appropriately managed. DS0000015063.V329755.R01.S.doc Version 5.2 Page 16 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. The Organisation has a robust complaints procedure which is accessible to service users and significant others, enabling them to make a formal complaint appropriately. Policies and Procedures are in place, which aim to protect service users from all forms of abuse, ensuring staff training is undertaken which enables staff to support vulnerable service users. EVIDENCE: The home follows the Organisations complaints procedure, which is reflective of timescales for action. A complaints log is in place, which is used to record all complaints, received at the home. It has been recommended this system be updated to ensure all complaints remain confidential, discussion on how to best achieve this took place with the manager. A recommendation to this effect is made. There have been no complaints received at the Commissions offices in relation to this service since the last inspection. All staff receives regularly updated POVA training, which is reflective of current guidance. The home follows the Milton Keynes Inter Agency Policy for the Protection of Vulnerable Adults (Safeguarding) and its reporting systems. There have been no reported or alleged POVA issues in the past 12 months. DS0000015063.V329755.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, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is cleaned and maintained to a high standard, providing a safe and pleasant environment for service users to enjoy. EVIDENCE: Marley Grove is a single storey building providing care for three service users with learning and physical disabilities. The home is situated on a residential housing estate close to local facilities and amenities. The home is pleasantly decorated throughout with personal touches such as pictures, photographs, fruit presented in a fruit bowl. The home is clean, spacious and bright creating a homely and comfortable surroundings for service users to enjoy. DS0000015063.V329755.R01.S.doc Version 5.2 Page 18 The kitchen is a newly fitted kitchen, which has been designed in line with the needs of the service users. Additional features such as height adjustable work surfaces make the kitchen accessible to wheelchair users. The kitchen is pleasantly decorated, clean and spacious. The communal lounge also has dining facilities; this is again pleasantly decorated with lots of personal touches. Furnishings are of a high standard providing a homely and cosy environment. The home has one bathroom, which provides a Parker Bath and a Walk In shower facility and toilet. Adaptations such as grab rails and hoists are provided to maintain a safe environment for service users. A separate toilet is also available in the home, which was found to be clean and spacious. Service Users are accommodated in their own bedrooms, which are all decorated and furnished in line with the service users personal preferences. There were no outstanding maintenance issues found on the day of inspection that would affect the health and welfare of the service users. DS0000015063.V329755.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, 33, 34, 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides adequate staffing levels to meet the needs of service users, however staff vacancies and the changed needs of service users could leave service users at risk. There is affective recruitment procedures in place to ensure service users are protected from harm. There is a full programme of staff training and development, however some staff still require mandatory training to ensure the ongoing safety of service users. EVIDENCE: The home presently has vacancies for a full time Deputy Manager, which has recently been advertised with no successful applicant, found. The Organisation will soon be re-advertising this post. In addition the home have a 30-hour vacancy for a senior support worker and a 30-hour vacancy for a support DS0000015063.V329755.R01.S.doc Version 5.2 Page 20 worker. The home presently covers these hours using their own staff or relief staff who are familiar with the service users. There is no use of agency at the home due to the lone working arrangements. The staffing numbers at Marley Grove are also used to support the 5 service users living at the Baxter Close services. It has also been brought to the commission’s attention that in addition to this staff are also supporting 2 service users living in a supported living service in Stoney Stratford (one of which is not funded by the Organisation). As the homes staff are not employed to provide Domicillary Care Services this practice must cease as soon as is reasonably practicable. A meeting to discuss this and other issues is scheduled with the Responsible Individual and the Operations Manager of the Organisation. In the interim a requirement is made that within 3 months the support given to the Service Users at Stoney Stratford’s supported living service is no longer to be provided by the staff employed at Marley Grove/Baxter Close. There has been one staff member recruited since the last inspection, the recruitment procedure for this staff member was assessed as satisfactory with all security checks in place which included a CRB (criminal records Bureau) disclosure and two written references. All recruitment is undertaken centrally with the Manager playing an active role during the interview process and checking the suitability of references. The Manager has developed a training matrix which highlights what mandatory training has been undertaken and when review courses are due. At this time some staff are awaiting updated manual handling, fire safety and medication training. A new contract has recently been agreed for an outside training provider to facilitate all mandatory training, the training programme is due to be distributed to the homes at the end of February 2007 which will support the manager to ensure all mandatory training and updates can be accessed. A requirement is made to the Manager that all outstanding or out of date mandatory training is to be undertaken by the 31st July 2007; this includes manual handling, fire safety and medication training. DS0000015063.V329755.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, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is supported well by the staff team in providing clear leadership and demonstrating an awareness of their roles and responsibilities to the benefit of the service users. The home has implemented a quality assurance system to ensure they are being proactive in identifying issues that may affect the wellbeing of service users. There are systems within the home, which are used to ensure that service users health, safety and welfare are protected and promoted. DS0000015063.V329755.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Manager is suitably qualified and experienced in her role; staff report her as approachable and supportive with regular staff meetings and 1:1 supervisions provided. Since her return from Maternity Leave she has worked hard to ensure the requirements of the last inspection report were complied with. There has been a noticeable improvement in the maintenance of the administration systems of the home since her return. The home has improved its quality assurance systems since the last inspection, ensuring systems already in place have been brought up-to-date and new monitoring tools implemented. An annual service user survey is undertaken with feedback used to support the manager to make changes to the way the service operates. An annual service development plan is produced which is reflective of the annual service aims and objectives formulated by the Manager with the Operational Manager. Weekly service users meetings take place. Regulation 26 visits are taking place with the last report reflective of November 2006. The home has robust health and safety procedures in place, which are reflective of current legislation and guidance. Six monthly health and safety inspections take place with the last recorded inspection December 2006. Monthly health and safety representative meetings are taking place for all Milton Keynes services, which are scheduled annually. Service records for equipment, gas servicing, PAT testing, C.O.S.H.H., hoists and specialist adaptations and equipment are taking place with records open to inspection. All three services have an individual fire risk assessment, which is updated annually. Regular fire monitoring is taking place with all requirements of the last Fire Authority inspection actioned. DS0000015063.V329755.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 “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X DS0000015063.V329755.R01.S.doc Version 5.2 Page 24 NO 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 YA33 Regulation 18 (1) a Requirement A requirement is made to the Organisation that within 3 months the support given to the Service Users at Stoney Stratford’s supported living service is no longer provided by the staff employed at Marley Grove/Baxter Close. A requirement is made to the Manager that all outstanding or out of date mandatory training is to be undertaken by the 31st July 2007; this includes manual handling, fire safety and medication training. Timescale for action 16/05/07 2. YA35 18 (1) c, i. 31/07/07 DS0000015063.V329755.R01.S.doc Version 5.2 Page 25 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. Refer to Standard YA17 Good Practice Recommendations It is recommended the Organisation purchase a set of sit on scales, which can be utilised as a resource for all of its services. DS0000015063.V329755.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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. 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