Inspection on 27/04/06 for Natalie House

This inspection was carried out on 27th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Natalie House 29/09/08

Natalie House 17/01/06

Similar services:

Flint House

The Ley Community

Yeldall Manor

Cherwood House Care Centre

The Manor Clinic

Francis House

1 Butler`s Drive

Stoneleigh

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

CARE HOME ADULTS 18-65 Natalie House 34 - 36 St Marys Road St Marys Southampton Hampshire SO14 0BG Lead Inspector Mr Richard Slimm Unannounced Inspection 27th April 2006 10:00 Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Natalie House Address 34 - 36 St Marys Road St Marys Southampton Hampshire SO14 0BG 023 8022 0580 023 8022 0580 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) Home Group Limited Care Home 10 Category(ies) of Past or present alcohol dependence (10), Past or registration, with number present drug dependence (10), Mental disorder, of places excluding learning disability or dementia (10) Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: Natalie House is a ten-bedded residential project, which provides accommodation to single men and women with enduring mental health problems. Support is provided 24 hours a day throughout the week. Accommodation is of a hostel model and is provided over three floors, lower ground and first floor providing the ten single bedrooms each with shower / WC en suites, and the ground floor, which provides the communal areas and staff office. The property would not be suited to people who are wheelchair dependent as access is poor. There is a communal kitchen/dining room, two lounges and a meeting room. Outside there is a large enclosed garden to the rear of the property, which could be further developed. There is a smoking room for those who wish to smoke. There are close links and specialist support available from the Southampton Community Mental Health services, supportive outreach services and the Department of Psychiatry. The home is situated in the city of Southampton in an area called St. Mary’s, which is residential and is also close to local shops and amenities and a short distance to the centre of Southampton. The service does not intend to provide drug/alcohol residential rehabilitation in-house, but may admit service users who have these needs identified secondary to mental health problems, and support such residents to attend community rehabilitation services. There is no intention for residents to be accommodated long tern, as the main aim of the service is to enable residents to re-gain and learn new independent living skills and to move on into move independent living/lifestyles, with appropriate support packages. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place on the 27/04/06 between the hours of 10 am and 5 pm. The inspector gathered evidence and information from reading documentation, staff files, service user files, observations and discussion with the residents, acting manager, project workers, visiting professionals, including Community Psychiatric Nurses, Occupational Therapists, and a student nurse and social worker. In addition the inspector spent time with service users case tracking one resident recently admitted, one more established resident and one resident who is about to be considered for moving on into more independent living. Other residents were interviewed and there was a high degree of satisfaction with the service being provided. The project’s manager will be making an application to register with the CSCI by the 10th May 2006. The inspector found evidence to support the view that this applicant has the necessary, skills, knowledge and experience to manage a service of this kind, however, this will be assessed further through the registration process. There are informal, in-house monitoring systems, which identify areas that need further development and improvement, and there was evidence that the service continues to develop and improve. There was evidence of a clear commitment to the ongoing development of the service and of a service that is prepared to work with the CSCI constructively to the overall benefit of residents. External professionals involved in the placement and support of residents were found to be very positive about the service being provided. Processionals stated that not only does the service enhance and improve the lifestyles of their clients/patients, but also the service is very cost effective for the local health trust. The staff files were inspected and there had been improvements in the detail and information being maintained, there was however, still some information omitted from a recently employed staff members file. Project workers confirmed that the manager had made improvements at the home in regard to staff recruitment, supervision, professional and induction training. The project workers on duty throughout the visit were observed in positive interaction with the residents. Service users were able to come and go from their home and the office area and were dealt with by staff in a dignified, sensitive and respectful manner. Service users were observed coming into the office to request their medication, which was given / administered observed by project workers. There was evidence that the project is supporting individuals with enduring mental health needs well. Those residents spoken to were found to be satisfied with the support they received, and the service works well and closely with other services that support people accommodated in the project. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The service should consider ways of improving and supporting the degree of empowerment of residents both within and external to the service. Service users should be involved in the ongoing development and design of the service to ensure it remains relevant and becomes more successful. While there was evidence of informal, individualised systems of consultation via key working and person centred planning, the service now needs to develop formal ways of ensuring the resident group are fully consulted about the development of the provision while they are accommodated. Systems will need to be developed to monitor residents when discharged to establish the success rates for those people moving on from the service, and to ensure adequate support is provided to promote and maintain their social inclusion, thus reducing the need for re-admission to hospital. Resident meetings, questionnaires and surveys may be some ways of promoting and increasing service user involvement and establishing their views. The service may also wish to develop exit interviews for service users who are moving on from Natalie House. While the home is beginning to meet the standards for staff supervision, there is a need to increase staff meetings to complement these improvements and to continue the excellent work done to date with team building. The garden area to the rear of the house is under used and appeared neglected. This area has significant potential for development to the benefit of residents especially during the warmer months. It is recommended that any development is low maintenance, which also promotes resident choice for individuals who may wish to become involved in gardening type activities. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 7 This report will make three requirements in the area of staff records for one new staff member, monthly visit requirements under Regulation 26, and the reporting of incidents under Regulation 37, in addition to a number of best practice recommendations. 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. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The service ensures that all prospective service users needs and wishes are assessed prior to admission. EVIDENCE: From the case tracking exercise there was evidence to support the view that the service fully assesses prospective residents needs and wishes prior to admission. This process is support by the excellent working relationships that have been developed with the community teams that are also supporting residents often with very complex needs. The service provides a range of options and choices geared to meeting service users needs and aspirations, but most importantly aims to provide safe refuge for very vulnerable people prior to moving on into more independent lifestyles. One resident confirmed that he had been given information about the service, and had been offered opportunities to visit prior to making a decision. Many residents need to be supported to make a decision about moving into the house, and this is often provided by external professionals and/or family advocates. Given the need to admit residents in emergency situations the service often relies on assessment materials provided by colleagues working with prospective residents in the community. This information is shared in a sensitive and professional manner. New admissions are provided with a pack to further promote informed choice for each new resident. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6-7-9 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users are fully involved in their assessments and care-plans. Service users are consulted as individuals. The service needs to promote methods for group consultation with residents. Risk taking is assessed and acknowledged as an essential aspect of promoting independence and quality of the life of residents. EVIDENCE: The service uses a person centred planning approach to document needs and wishes of service users and to plan the necessary inputs to achieve individual goals. These systems are updated and reviewed in order to keep track of changing needs. Service users spoken to knew about their personal case records and are enabled to partake in the development of their plans with key workers and external professionals. There was clear evidence that individual residents are supported and encouraged to make decisions about their lives, and are offered support and guidance where needed. Residents confirmed that they felt in control of things and were receiving support when needed in a sympathetic and understanding way. Residents spoke highly of staff and were Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 11 aware of who their key worker was. Care plans included risk assessments that appeared to be applied in a flexible, safe and user-friendly way. The inspector case tracked three service users’ and was able to involve these residents in the assessment process of the service. Two other service users were interviewed one briefly to avoid causing anxiety, and all residents spoken to stated that they were happy living at Natalie House. Service users confirmed that they are supported and encouraged to make everyday decisions about their individual lives. Service users were observed to come and go from the project as they pleased throughout the visit. Visitors were evident and the inspector briefly met and spoke to one visitor of a resident. Posters had been displayed around the home to remind residents of activity groups that were running at the home. Service users need increased input, encouragement and support to attend resident meetings and these meetings will need to be facilitated by a skilled and trained group worker to enable residents to fully engage in making decision within groups about how their home is run. This is also an essential aspect of a service that aims to provide opportunities for people recovering from mental health problems to re-learn social skills to facilitate further social integration. Other forms of consultation should be developed with service users to promote their involvement in the services ongoing development. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-13-14-15-16-17 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The service promotes opportunities both inside and outside the house for residents to develop as individuals. Service users are treated with dignity and respect, and encouraged to participate in activities that are valued. Appropriate leisure activities are provided. Residents are encouraged and supported to retain safe relationships outside of the home, and can entertain visitors at any reasonable time. The service promotes and supports residents in exercising their individual rights and responsibilities in daily living, and provides a full varied and balanced diet, with an emphasis on residents re-learning and learning new independent living skills. EVIDENCE: Interviews with residents, person centred planning documents and discussions with staff provided a range of evidence to support the view that the standards above are promoted. Residents engage in local day services if they wish. The service links with City Limits a local employment agency and 2 residents confirmed that they had been found voluntary work as part of their personal Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 13 development and aim to seek paid employment longer term. Residents have access to external advocacy via Rethink (formerly NSF). There are in-house groups for both genders, and the home is close to all local facilities such as the library, town centre etc. The people living at Natalie House said they felt part of the local community, and that the staff members support them to engage in leisure activities of their choice. Residents are supported to entertain visitors, and a number of visitors were observed throughout the visit, and residents confirmed they are able to have visitors to their home. Key working supports individual residents to partake and to retain their rights and responsibilities. The service provides a range of different foods based on the needs and wishes of the residents. Residents are encouraged and supported to gain and/or re-learn skills in the kitchen. Residents said the food was good. The service will be employing an additional staff member soon to work specifically with residents and to support residents to improve cooking skills and keeping their home clean, tidy and running smoothly. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 this service. Service users are provided with individual packages of support and care that meet their needs and preferences. Residents emotional, physical and health needs are met in partnership with residents and other relevant professionals when needed. EVIDENCE: Key working systems and person centred care planning promotes individual support packages that appeared to accurately reflect the needs, aims and aspiration of the resident. Residents and visiting health care professionals confirmed that the home works hard to ensure the physical, emotional and health care needs of residents are met. Care planning systems also promoted and protected resident’s rights to access health services in similar ways to other people in the local community, and needs and wishes were clearly documented. Residents are risk assessed and all are encouraged to gain the necessary skills to become more independent with regard to their medications. This was supported by comments from residents, staff, observations and records. Arrangements for the storage, administration and recording of drugs and medicines were found to be safe at the time of the inspection. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 this service. The service has a user-friendly complaints procedure. The service should be more proactive and imaginative about how it consults residents as a group. The service has systems in place to protect residents from abuse, neglect or harm. EVIDENCE: All residents are given a comprehensive guide to the service when admitted this is called “Involving You” (Welcome to Stonham Your information Pack). This pack contains all the information a tenant may need who uses one of Stonham’s services and includes a full explanation of the complaints processes and procedures. Residents spoken to confirm that they had been provided with this information on admission to the house, and were also able to explain whom they would speak to if they had a concern and how they could make a complaint. No residents had made any complaints since the service was registered in 2005. The manager was able to demonstrate an understanding of how to deal with complaints in a professional and sympathetic manner. A complaints log is available as well guidance for staff dealing with these issues. The pre-admission information pack is supported by pictorial symbols to assist residents to understand their rights. The manager advised the inspector that Stonham provide all staff with training in such areas as adult protection, and that the home has guidance about local adult protection procedures. The manager was able to demonstrate an understanding of his responsibilities in this aspect of the service and promoting the protection of vulnerable people in his care. The degree to which the service user group are consulted as a group appeared t be limited. Historically attempts to hold resident meetings have Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 16 failed, due in part of a lack of resident motivation, not uncommon in the area of mental health. Consequently the service needs to look at developing forums and other methods of consulting and empowering the resident group, and ensuring that residents’ views are sought about the running of the home and the home’s ongoing development as a service. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. This service does not claim to be a typical residential care home, and is not a drug and alcohol rehabilitation service. The service aims to enable residents recovering from acute mental health problems and dysfunctional lifestyles, accommodated short term to move on into more independent living, and/or their own homes supported where necessary. However, the hostel provides a clean, enabling and valuing environment and residents are encouraged and supported to take a pride in their temporary home. The home was well maintained and cleaned to an acceptable standard, given the high ware and tear some areas of the service are subject to. The garden area needs further development and improvement. EVIDENCE: A full description of the layout of the home’s facilities is identified above. The service provides a hostel style accommodation and residents usually will not remain living at the hostel in excess of 2 years. The service aims to move residents on into more independent living in the community. Every effort is made to make the environment as valuing as possible. Each resident’s room is single and has an en suite shower and toilet. Each room is lockable and a safe Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 18 is provided in each room to store valuables. All residents have locks to their rooms and safes. Residents said they were very satisfied with their rooms and living at the house. The garden area is unkempt and needs development in line with the wishes and needs of residents. The manager is keen to develop the garden but this is currently restricted due to a lack of funding resources. It is clear the garden could be used more for residents especially now the warmer weather is coming. One resident did acknowledge that the garden was untidy. The home was cleaned to an acceptable standard, and residents confirmed that they are supported to keep their house clean and tidy. The introduction of a staff member with specific responsibilities around catering and housekeeping should improve this aspect of the service and increase opportunities for resident involvement and improving skills in this area of daily living. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32-34-35 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The service provides a competent and committed staff team to support residents. The organisation adopts clear and safe practices in staff recruitment in order to promote the protection of residents. The staff team may benefit from group work training; in order to be enabled to further meet the joint needs and develop social skills and social interaction with the resident group. EVIDENCE: Residents spoke highly of the staff team. Staff members were able to demonstrate an awareness of the needs and wishes of residents. Staff members are being enrolled onto the NVQ course being run at the local Department of Psychiatry to obtain a mental health relevant qualification. Other core training is being provided and there are plans for the manager to begin providing in-house specialist mental health training. There was evidence that staff may benefit from some group-work training in order to improve service user motivation, involvement and consultation as a group, via the facilitation of resident group meetings. External professionals stated that the staff team are both competent and clearly committed to providing a quality service for residents. Action had been taken to improve the quality of staff records. However, one newer staff member’s recruitment records were not complete and available in the service. This information is still being kept at the Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 20 organisations HQ. The inspector observed aspects of the home’s staff checking systems and staff who had not received CRB checks had POVA checks done prior to working supervised in the house with vulnerable residents. All other staff records were maintained in line with legal requirements and the manager had done a lot of work in this area since the last inspection. There was clear evidence that the individual needs of residents are met, however, more development is needed to ensure the joint needs of the group are met in the area of group consultation and control. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37-39-42 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home is well managed and run efficiently and is sympathetic to the special needs of the resident group. Individually residents needs are well met, however, further developments and quality assurance needs to be developed to further promote the role involvement of the whole resident group. The manager of the house is committed to promoting and protecting the health and safety of residents and staff. EVIDENCE: There was evidence that the home is run efficiently and effectively. External professionals stated that they believed the service was excellent value for money and had been very impressed since the service opened in 2005, how their very vulnerable clients lifestyles had improved, as well as their mental health stabilised. The house provides a supported and stable environment to people who have led fairly chaotic and dysfunctional lives due to their social exclusion and mental health problems. This enables their community support Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 22 workers to begin to work effectively with their patients and start to plan for future independence and social inclusion. Residents spoken to say they were satisfied living at Natalie House and in their view the home was well run and the staff team were good. Each resident has an individual plan of care a key worker and support that links closely with the work and planning of the community mental health care team and supportive community outreach hospital teams. One community nurse and occupational therapist said the service was very good, and saved the health care trust significant money by reducing emergency admissions to hospital under very stressful circumstances for both individual patients, their families and professionals involved. As identified above the service needs to develop methods that enable the residents as a group to voice their views as to future developments, but it is clear that there is no lack of commitment from the staff team to the ongoing development and improvement of the provision. It was noted that a high number of residents smoke both in designated areas of the home and their individual rooms. The house benefits from a modern, fully integrated, fire alarm system and smoke detection system, but it is essential given the potentially transient nature of the resident group that fire drills and education of residents in fire related matters needs to be very vigilant. Residents spoken to said they felt safe at the house, and appreciated the support they received, which is provided based on their individually assessed needs and wishes. The manager makes necessary arrangements to ensure that health and safety at work is promoted which further promotes the protection of vulnerable residents and also the staff team/visitors etc. This is underpinned by comprehensive policies and procedures that have been developed by the organisation that is registered to provide this service. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 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 X 34 2 35 3 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 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 x 2 x x 3 x Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? YES 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 19 Sch 2 Requirement Timescale for action 10/06/06 2. YA38 26 3. 4 YA42 YA37 37 8-9 All staff files, including new staff must contain evidence to demonstrate adequate recruitment procedures that protect residents as required under schedule 2. The registered person shall make 10/06/06 arrangements to visit the home each month and provide a report to the home and the CSCI with regard to the conduct of the home. The service must report any 10/06/06 incident as identified under Regulation 37 to the CSCI. The manager must make 10/06/06 application to be registered with the CSCI. Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 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 YA8YA39 Good Practice Recommendations Staff should be provided with training in group-work skills. Residents should be encouraged, motivated and supported to be involved in regular resident meeting about their home, the running and of the home and the ongoing development of the service provided at the home. The service should utilise other system of seeking the views of residents including surveys, questionnaires and may wish longer term to introduce exit interviews for residents who are moving on. Professional staff supervision should be regular and meaningful for each individual staff member. Staff meetings should regular and attended by all members of the staff team across both day and nigh-time teams. The garden area should be improved and developed in consultation with residents and thought given to the need of future residents, in the context of how the area will be maintained longer term. 2 YA36 3 YA24 Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Natalie House DS0000065704.V287656.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!