Inspection on 01/02/07 for Mayfair Avenue (3)

This inspection was carried out on 1st February 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

Mayfair Avenue (3) 26/01/06

Mayfair Avenue (3) 09/05/05

Mayfair Avenue (3) 31/01/05

Mayfair Avenue (3) 24/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Mayfair Avenue (3) 3 Mayfair Avenue Ilford Essex IG1 3DJ Lead Inspector Jackie Date Unannounced Inspection 1 – 9th February 2007 12.30 st Mayfair Avenue (3) DS0000025910.V328881.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 Mayfair Avenue (3) DS0000025910.V328881.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. Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfair Avenue (3) Address 3 Mayfair Avenue Ilford Essex IG1 3DJ 020 8518 2839 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.mencap.org.uk Royal Mencap Society Ms Kathleen Hegarty Care Home 5 Category(ies) of Learning disability (6) registration, with number of places Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mild to moderate learning disability. Date of last inspection 26th January 2006 Brief Description of the Service: 3 Mayfair Avenue is one of four homes operated by Mencap in the London Borough of Redbridge. The home is situated in a residential street close to Ilford Town Centre. There is easy access to public transport, shops and leisure activities. The home is a large terraced house with four bedrooms, a bathroom with toilet and a shower room with toilet upstairs. Downstairs there is a large open plan through lounge, kitchen, office, staff sleep-in room, laundry area, toilet and one bedroom. The house is well furnished and decorated. The bedrooms are individually decorated and personalised according to residents likes and interests. There is also a small well-maintained garden. Five adults with learning disabilities live at the home and they all need a lot of assistance and support from the staff team. Two of the residents have little or no verbal communication and have limited ability to make decisions about their lives. The residents are encouraged to be as independent as possible and three have access to day services for all or part of the week. Residents are encouraged to keep in contact with their families and are supported by the home to do this. The scale of charges is approximately £1200.00 per week. This information was provided in the pre inspection questionnaire. Information about the service provided is contained in the service users guide. Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit lasted for about five hours and took place during the afternoon. A second shorter visit was made to talk to the manager and to check staff files. The staff and the residents were spoken to. All of the shared areas and two of the bedrooms were seen. Staff, care and other records were checked. Staff were asked about the care that residents receive, and were also observed carrying out their duties. Relatives were contacted and asked for their opinions of the service. Feedback was received from the relatives of four of the five residents. This was a key inspection and all of the key inspection standards were tested. What the service does well: What has improved since the last inspection? What they could do better: The manager and staff are committed to provide a good service for the residents and this is reflected in the feedback from relatives and the fact that there is only one requirement from this inspection. The stair carpet needs to be replaced before it becomes a danger to residents and staff. Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 6 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. Mayfair Avenue (3) DS0000025910.V328881.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 Mayfair Avenue (3) DS0000025910.V328881.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, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to enable the staff team to meet residents’ needs. If a vacancy arose the required information would be gathered on a prospective resident and they and their relatives could spend time in the home to find out what it would be like to live there and to enable the resident to make a choice about living in the home, within their capacity to do so. EVIDENCE: The residents have lived together for several years. Therefore there have not been any recent new admissions. The organisation has an admissions procedure that includes gathering of information and assessments. It also contains details of how a prospective resident would be introduced to the home. The staff are aware of this and would be able to assess and introduce a new resident to the home if needed. Each resident has a detailed care plan that contains information about what they can do, their likes and dislikes and what help and support they need. The residents appear to be happy and relaxed in the company of the staff and in the home. Residents that were able to say that they liked living there. Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 9 Mayfair Avenue (3) DS0000025910.V328881.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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ plans focus on their individual needs and abilities and contain detailed information so that staff can meet their needs. Risk assessments are appropriate and reviewed and up to date. Therefore residents’ are supported to take risks according to their needs. Residents are consulted about what happens in the home as far as they are able. EVIDENCE: Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 11 All of the residents have plans which give details of how they need/like to be supported. Areas covered included health, personal care, communication and behaviour. A selection of care plans were examined during the visit and the information contained in them was relevant and detailed. They also indicate what individuals can do and what support that they need. For example one residents’ care plan states that she needs help to wash her hair and her back but that she can dry herself. The home is working towards Person Centred Planning(PCP)and residents have PCP folders which contain photographs of the resident, their family and of things that they do and like. This helps residents to understand what is in their plans and is good practice. Residents’ plans contain sufficient information so that staff can meet their needs. Daily recordings are made about what each person has done and support that they have been given. These recordings are broken down into various areas including choice, community presence, skills, physical and emotional health and personal care. Therefore there is information about each individual, which can be used as part of the review process and to identify ongoing and changing needs. There are risk assessments in place. These identify risks for the residents’ and indicate ways in which the risks can be reduced to enable the residents’ needs to be met as safely as possible. Risk assessments are also relevant to each person. Risk assessments examined had been reviewed and updated and therefore current information was available. Residents meetings are now held each month and a record is kept of these. Three of the residents can and do express their views about what they want to do and what they like. Residents were asked what they wanted to do at Christmas and where they would like to go. They are also involved in choosing what they eat and in decisions about the building, e.g. what colours they like. Staff spoken to confirmed that residents are encouraged to make choices. The residents cannot look after their own finances and staff have to help them. Residents can indicate what they want to buy when given choices in the shop and staff support them to do this. Therefore the residents are involved in the running of the home as far as they are able. They are encouraged to make decisions about what happens as far as they are able. Residents’ records and other information are stored in a lockable cabinet in the office and staff are aware of issues of confidentiality. Mayfair Avenue (3) DS0000025910.V328881.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): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are encouraged to be as independent as possible, to take part in activities and to be part of the local community. Residents are supported to keep in contact with their relatives and visitors are made welcome at the home. Residents are given meals that they like and that meet their needs and individual preferences. EVIDENCE: Three of the residents have access to day services. The amount of day services varies from two days to five days per week. Additionally, they have allocated ‘key days’, when they have one-to-one input from a key worker. This includes visits and activities as well as personal shopping and care of Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 13 bedrooms. Since the last inspection two residents have “retired” from their day service. This was due to changes in the age range that the day service is now provided for. Both residents found the change difficult but have been supported by the staff team who are in the process of developing other activities with these two residents. One person is waiting for clearance from the doctor so that he can go horse riding and swimming. Residents are encouraged to develop their skills and each person contributes to the tasks in the home in as far as they are able. This may be to help clear the table, wash up or put the rubbish in the bin. Daily notes reflect what residents have done. For example “ cleared the plates”, “got a knife and fork from the drawer”, “emptied the rubbish”, “took clothes to the laundry”. Staff spoken to said that residents are encouraged to do as much as they are able and are offered choice in areas of meals, where to go, when to go out and what to wear. All of the residents need support from the staff team when they go out. They visit local pubs, leisure facilities, shops and cinemas. Residents said that they had enjoyed Christmas. One of the residents enjoys going shopping for clothes. Residents are asked where they want to go and what they want to do and the staff team also base decisions on their knowledge of individual likes and preferences and how residents respond to new and different activities. Two of the residents enjoy going to the cinema, another likes going to the pub. On the first day of the inspection two residents were at day services and the other three had been out during the morning and returned with a takeaway meal that they had chosen. During the second visit two of the residents went shopping, with staff, in Romford and were looking forward to having lunch there. Four of the residents have regular contact with their relatives. Feedback from one relative was that the family receive a warm welcome when they visit and that Mayfair provides the residents with a home from home atmosphere. Another relative said that he is not able to get to the home but staff regularly bring his son to see him even though he does not live locally. Residents are encouraged and supported to keep in contact with friends and relatives. Residents and staff usually eat together. Residents are involved in choosing what they eat and also staff know residents likes and dislikes. Residents said that they had enjoyed their meals. Residents care plans contain information about their dietary needs and likes and dislikes. One care plan seen stated “ I like pasta, eggs, roast dinner and fish and chips.” One resident has diabetes and the staff team support him to have an appropriate diet. Residents are given meals that they like and that meet their needs and individual preferences. Mayfair Avenue (3) DS0000025910.V328881.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 judgment has been made using available evidence including a visit to the service. Residents receive personal care that meets their individual needs and preferences and the staff team support them to get the healthcare that they need. Residents are given their prescribed medication safely. EVIDENCE: The residents require support with their personal care and details of the help that they need and how they prefer to be supported are in their individual plans. One resident’s plan states “I need you to wash my back and my hair. I can dry myself.” Residents are encouraged to choose what to wear and at the time of the visit were all smartly dressed. Residents receive personal care that meets their individual needs and preferences. All of the residents go to the local doctor and specialist help is received when needed. Staff take residents to all of their medical appointments. Residents’ files have details of health care issues and show that residents have regular access to health care professionals. Records are kept of medical appointments and these show that residents have checks from the optician, dentist and when Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 15 needed the chiropodist. A resident has diabetes that is controlled by diet. Records show that the staff monitor this regularly and take the necessary action if any problems arise. For example to give him something to eat or drink and then check again. His diabetes is well managed and controlled by the staff team. Another resident had gained a lot of weight, which was affecting her health & mobility. With support from the staff team in terms of diet and more exercise she has lost more than a stone in weight. The same resident has been to the doctor regularly with regard to her health needs and her relative confirmed that her health needs were being addressed. Records also show that residents have access to health screening and that they have had drug reviews. Therefore residents’ health care needs are being met. None of the residents are able to self medicate and staff that have received medication training administer medication. The list and specimen signatures of those trained and authorised to administer medication is on file. The medication administration records (MAR) file contains photographs of the resident and details of any allergies. This is good practice as it lessens the chance of medication being given to the wrong person. Medication records had been appropriately completed. One of the residents has to take a medication one hour before food and during the course of the visit it was observed that this was given at an appropriate time before the evening meal. The pharmacist had visited on 17/1/07 and found everything in order. Medication is securely stored in a locked metal cabinet in the office and is appropriately administered by the staff team. Mayfair Avenue (3) DS0000025910.V328881.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 judgment has been made using available evidence including a visit to the service. The complaints procedure is in a pictorial format to help residents understand how to complain. Staff have received adult protection training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. This gives residents a greater protection from abuse. Residents’ finances are adequately managed and monitored and this lessens the risk of financial abuse. EVIDENCE: There is an organisational complaints procedure and the staff team have developed a version with photographs for the residents. This includes photos of the manager, service manager and the inspector. This is a very good piece of work. Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 17 Mencap has produced a detailed adult protection policy that tells staff the actions to take in the event of abuse/suspected abuse being discovered. Staff have attended a course on protecting residents from abuse and are aware of their responsibility to residents. All of the relatives spoken to said that they were very happy with the care provided and also that their relatives were happy living at Mayfair Avenue. All of the residents need help with their finances and have limited capacity to understand about the concept of spending or saving money, other than that money is exchanged for goods. Records are kept of financial transactions. Regular checks are made by the manager to ensure that these are correct. All of the cash held for residents’ was checked at the time of the inspection. Four were correct but there was a small discrepancy on the other one. The manager was sorting this out during the course of the visit. Appropriate receipts were on file. Residents’ finances are appropriately managed and monitored. Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 18 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 judgment has been made using available evidence including a visit to the service. The residents live in a clean and comfortable home that is suitable for their needs. EVIDENCE: Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 19 The house is in Ilford and is near to the local shops, bus routes and train station. The home is clean and well maintained. The lounge and dining area are combined and the kitchen is open plan. The building is non-smoking. None of the residents smoke. The office and staff sleeping-in room are on the ground floor. There is no separate visitors room but residents can meet visitors in the office if they wish. There is a small well-maintained garden that is used by the residents. There is a toilet on the ground floor and a shower room with toilet plus a bathroom with toilet upstairs. There is a separate utility area with laundry facilities Each resident has a single bedroom. These are decorated and furnished to meet individual needs and likes. On the day of the visit two of the residents showed the inspector their bedrooms and these were both personalised to suit the resident. There is also one bedroom on the ground floor, which could be used for someone with reduced mobility but as previously stated the shower and bathing facilities are upstairs. At present none of the residents need any specific adaptations. During the visit the home was clean and free from offensive odours. The stair carpet is very worn and the manager said that she has been getting quotes for it to be replaced. The manager was advised that the stair carpet must be replaced within one month so that it does not present a risk to staff and residents. The house is very comfortable and homely and suitable for the needs of the residents. Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 20 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 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are receiving the necessary training to give them the skills to meet residents’ current needs and provide an appropriate service for them. Staffing levels are sufficient to allow for this Staff are properly recruited and the necessary checks carried out. This helps to protect residents and keep them safe. In addition to informal support staff receive formal supervision and regular staff meetings are held. This gives a chance for work practice and the development of the service to the discussed. Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 21 EVIDENCE: Since the last inspection new staff have been recruited and there is now a full staff team. Therefore sufficient staff are now employed to provide a consistent service to residents, as required by the previous inspection. A minimum of two staff are on duty at peak times. In addition to this a third member of staff is on duty during the day to support residents with activities. Additional staff are also on duty on for specific activities or appointments. Feedback from staff was that this was sufficient to meet residents’ needs. At night there is only one member of staff sleeping in, but with access to support in the event of an emergency. Feedback from staff was that this was a satisfactory arrangement, as residents rarely needed support during the night. From discussions with staff and examination of training records it was evident that the staff team have been receiving training that enables them to carry out their duties and to meet residents needs. For example one staff training record for 2006 showed training in oral hygiene, Protection of Vulnerable Adults, infection control, risk assessments and bereavement. Three staff have achieved NVQ qualifications and another was booked to commence NVQ level 3 the week after the inspection. The staff team all have a lot of experience of working with people with learning disabilities. Therefore an appropriately trained and experienced staff team supports the residents. The organisation operates an appropriate recruitment procedure. Jobs are advertised, application forms completed and interviews held. The necessary checks are undertaken prior to staff commencing employment. A random sample of staff records held in the home were checked during the inspection. These contained the necessary information and confirmation that appropriate checks had been made. Therefore the recruitment process offers safeguards to residents. The previous inspection required that all staff must receive regular formal supervision, in addition to day-to-day contact, in order to provide support and guidance and to monitor work with the residents. The feedback from staff was that they are receiving regular supervision and that there are regular staff meetings. They therefore have the opportunity to both individually and collectively discuss any concerns, developments and residents needs. All of the staff spoken to said that they were very well supported by the manager and each other. Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 22 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. Appropriate management arrangements are in place to ensure that a good quality of service is provided to residents. The home is well managed and provides a safe environment for the residents. The registered provider monitors the service appropriately to check the quality of the service provided to residents. EVIDENCE: The manager has a lot of experience of working with people with learning disabilities and of managing residential services. Feedback from relatives was that the manager is a good manager and that their relatives are happy Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 23 because of the good quality of service provided. Feedback from staff was that they feel well supported and one member of staff said, “I can use my initiative and make suggestions”. A representative of the organisation carries out monthly unannounced monitoring visits to the home and a report on this visit is left at the home and a copy of this sent to the Commission. The reports cover the necessary areas and indicate any action that is needed. An annual service review is also carried out. Therefore the quality of the service provided to the residents is monitored by the organisation. All of the necessary health and safety checks are carried out and the building is kept safe for all that use it. Hot water temperatures were being tested weekly but very recently this has changed to monthly. This was discussed with the manager and she confirmed that this was an error and that it should be weekly. She said that this would be rectified. Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 24 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 3 4 3 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 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 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 3 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 3 X X 3 X Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 25 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 YA24 Regulation 13, 23 Requirement The stair carpet must be replaced. Timescale for action 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Mayfair Avenue (3) DS0000025910.V328881.R01.S.doc Version 5.2 Page 27 - 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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