Inspection on 15/01/07 for Peterborough Avenue

This inspection was carried out on 15th January 2007.

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

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

Other inspections for this house

Peterborough Avenue 11/01/06

Peterborough Avenue 19/12/05

Peterborough Avenue 21/03/05

Peterborough Avenue 08/07/04

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 Peterborough Avenue 71 Peterborough Avenue Cranham Upminster Essex RM14 3LL Lead Inspector Mrs Sandra Parnell-Hopkinson Key Announced Inspection 15th January 2007 01:00 DS0000027888.V326784.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 DS0000027888.V326784.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. DS0000027888.V326784.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Peterborough Avenue Address 71 Peterborough Avenue Cranham Upminster Essex RM14 3LL 01708 225196 01708 223189 ritalewis2004@ntlworld.com 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) Ms Rita Antoinette Lewis Ms Rita Antoinette Lewis Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000027888.V326784.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 2006 Brief Description of the Service: Cara Linn Care Home at 71 Peterborough Avenue is a care home registered to provide long term care, support and accommodation to 3 adults with learning disabilities. The home operates as a small family home and is situated in a residential area of Cranham, and is close to local shops, major road links and public transport. The house is semi-detached with car parking facilities to the front of the home, and the rear garden is well maintained with flowerbeds, lawn and patio. Residents’ independence, choice, dignity and respect is promoted at all times, and they are encouraged to participate fully in the life of the community. A copy of the statement of purpose and service user’s guide, together with a copy of the last inspection report, was available in the hallway of the home and a copy of the statement of purpose will be sent on request to the manager. Currently all of the three places are commissioned by the London Borough of Havering who have agreed fee levels with the proprietor. DS0000027888.V326784.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced key inspection undertaken by Mrs. Sandra ParnellHopkinson as the lead inspector, and the inspection was commenced at 13.00 hours. It was an announced inspection to ensure that the inspector could meet with residents as well as with the staff and the proprietor/manager. The three residents all said that they were very happy living at Peterborough Avenue, and it was very apparent that they had a good rapport with staff and the proprietor/manager. It was very obvious that the home is operated for the benefit of the residents, and that their needs are of paramount importance. Previous requirements have been complied with and no further requirements have been made at this inspection. What the service does well: Information about the home is comprehensive and the statement of purpose and service user guide have been produced in a pictorial format for the ease of the service users. The complaints procedure has been produced in a simple pictorial format and a copy of this is kept in each of the resident’s bedroom. Before prospective residents and their relatives make a decision on whether to move into the home residents are invited to spend the day at the home as a main part of the assessment process. Care plans and risk assessments are extremely comprehensive and cover all aspects of the care of the resident, and the manager ensures that residents are fully involved in the development of the care plans and risk assessments. Residents are also fully involved in completing their life histories and activity books. The manager has a very good relationship with health and social care professionals, and the three residents regularly attend the chiropodist, dentist and GP. Activities are very focused on residents retaining daily living functions such as washing, dressing and undertaking any household functions such as helping to clear tables, dusting, keeping rooms tidy and conversing. Being part of the local community is also a very important aspect of life at Peterborough Avenue, and the staff and manager ensure that there is up to date information available in the home on theatres, trips, concerts, friendship groups and if a resident wants to arrangements are made for employment opportunities. DS0000027888.V326784.R01.S.doc Version 5.2 Page 6 It was very evident that the home is operated for the benefit of residents, and every effort is made to retain their independence and for them to continue to exercise choice and control over their lives. The routines of daily living and activities are flexible and varied to the individual needs and capacities of residents, together with their religious and social preferences. Currently all of the residents are white British and of a Christian persuasion. Training courses for care workers is of a high standard, and the low turnover and sickness levels for staff has meant that a consistently good service is delivered to residents. What has improved since the last inspection? 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. DS0000027888.V326784.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 DS0000027888.V326784.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): 1, 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives have the information required to enable them to make an informed choice about where to live, and do not move into the home without having had a comprehensive assessment of need undertaken, and been assured that these will be met. Both service users and their relatives have an opportunity to visit and assess the quality, facilities and suitability of the home before making a decision to move in. All service users are given a statement of terms and conditions with the home. EVIDENCE: The statement of purpose and service users guide include detailed information about the service provided and this is available to all prospective residents and relatives, and is available in a pictorial format. Before a decision is taken to accept a new resident, that person is invited to spend a day at the home so that the manager and her staff can undertake a very comprehensive assessment of the person’s needs. Because this is a small home other residents and staff help them to feel comfortable in their surroundings, and initially endeavours are made to ensure that they are not unduly confused with too much information. DS0000027888.V326784.R01.S.doc Version 5.2 Page 9 Relatives and friends are told that their support and involvement in the continued care of the resident is important, and that they can bring in familiar objects that have real meaning to the person. Following the visit by a prospective new resident, the manager, residents and the staff team consider the application and views and opinions/comments are listened to and fully discussed before the admission is agreed. In a small home of three people it is essential that as far as is possible residents are able to live together. Care staff at the home have undertaken training in caring for people who have a learning disability, and are fully able to understand the constantly changing needs of these residents. DS0000027888.V326784.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 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The assessed and changing needs and goals of service users are reflected in their individual plans, and they are enabled to make decisions about their lives with the necessary assistance. Service users are consulted on, and can participate in, all aspect of life in the home and are supported to take risks as part of their independent lifestyle. Information on service users is handled appropriately and service users can be assured that their confidences are maintained. EVIDENCE: The files of the three residents were inspected, and as all of the residents were present during the inspection it was possible to discuss the care plans with the residents. All three files showed clear evidence of a comprehensive assessment of need, and personal goals for the residents had been reflected in their individual plan. DS0000027888.V326784.R01.S.doc Version 5.2 Page 11 It was clear that residents were enabled to be as independent as possible within a risk management framework. One of the residents liked to be very independent and enjoyed going out during the day. He has a very detailed risk assessment in place for travelling on public transport, in that he must sit downstairs on the bus and at the front near to the driver, always keep some money for emergencies and has been given a mobile telephone with the number of the care home easily accessible to him in case of the need to make an emergency call. All of the residents said that they liked living at the home, and it was evident during the inspection that they treated this as their home. Another resident is now finding it difficult to walk long distances but does not want to use a wheelchair, and therefore, consideration is given to this when organising outings. All of the residents are encouraged to take part in all aspects of life in the home, and one resident proudly told me that “I bring my dirty washing down from my room.” Currently all of the residents are of a Christian persuasion and all are encouraged to participate in their local church activities. It was obvious from talking to them that they enjoyed taking part in these activities. With regard to finances, support is available to enable the residents to purchase toiletries, clothing and other miscellaneous items. Receipts and records are being maintained for all expenditures made by staff on behalf of residents, but all of the residents are encouraged to take responsibility for managing their own money with support where necessary. The inspector was satisfied that information about residents is handled appropriately and that confidences are maintained where necessary. Records are kept securely in a lockable filing cabinet. DS0000027888.V326784.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, 14, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are able to take part in age, peer and culturally appropriate activities, are part of the local community and are encouraged to maintain appropriate relationships with family and friends which is to the benefit of all parties. Service users’ rights are respected and responsibilities recognised in their daily lives. A healthy diet is offered so that service users can enjoy meals and be assured that their dietary and nutritional needs are being met and monitored. EVIDENCE: It was evident from inspecting the care plans of the three residents, and talking to them that they have been able to inform staff as to their wishes and needs. The three residents are white British and of a Christian persuasion and activities are culturally appropriate for them. The religious needs of these residents are also met with the encouragement and support of the manager DS0000027888.V326784.R01.S.doc Version 5.2 Page 13 and the staff. All care plans are under monthly review, or sooner if changing needs of any of the residents necessitates earlier and more frequent reviews. The manager and her staff are very proactive in finding out information on activities which may be taking place within the local and wider community. There are frequent trips to theatres, concerts, museums, sites of interest such as the Tower of London, Tower Bridge and the London Eye, and all of the residents are encouraged to keep an activities book in which they keep pictures, photographs, programmes and also are encouraged to write a small sentence under each entry. They also go to see some television programmes and very proudly showed the inspector a video in which it was possible to see the residents in the audience. This caused much laughter during the inspection. Home activities are also encouraged and the residents enjoy doing jigsaw puzzles, and some of these are extremely complex and up to a 1000 pieces. Residents are also encouraged with developing skills around numeracy and literacy. Family and visitors are always welcome at the home, and during the recent Christmas celebrations all of the residents had a visit from a relative. The home is very much a family home and is treated as such by both staff and residents. There is a quiet room and a conservatory if residents wish to entertain visitors in areas other than their bedrooms. One of the residents did voluntary work at a local hospital before he was made redundant due to the closure of that hospital. However, the manager is now actively engaged with this resident in finding other employment through the R.O.S.E. project (realistic opportunities for supportive employment). Residents are encouraged to personalise their bedrooms and they all enjoy being in their rooms at times, and again took great pleasure in showing the inspector around the home and in particular showing her their own bedrooms. A comprehensive menu was available, and again it was very evident from observation and from discussions with the residents that they choose what they want to eat, and often help with some of the preparation. The manager and staff do ensure that residents are receiving a healthy and balanced diet with plenty of fresh produce. However, it was also evident that much work is required in the motivation of residents to encourage them to undertake tasks that they may have little interest in. This encouragement is given with great understanding and kindness with no pressure being put on the residents. The interaction between the manager, staff and residents was excellent and the residents appeared very comfortable and relaxed in the presence of the staff. It was evident from observation that staff showed respect and valued the residents as individuals. One member of staff had just returned from holiday, and she was greeted with great enthusiasm and joy from the three DS0000027888.V326784.R01.S.doc Version 5.2 Page 14 residents when she commenced her afternoon shift. All of the residents were anxious to her about her holiday. DS0000027888.V326784.R01.S.doc Version 5.2 Page 15 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 and 21. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users can be assured that they will receive personal support according to their wishes and that their physical, emotional and health needs will be met by the involvement of appropriate professionals where necessary. Where appropriate, service users will be able to retain, administer and control their own medication within the protection of the home’s medication policies and procedures. EVIDENCE: From viewing the care plans of the three residents it was evident that their physical, emotional and health care needs had been identified. All are registered with a local GP, dentist and optician, and it was evident from the records and from talking to the residents and staff that regular visits are made to the dentist and the optician, and to the GP when necessary. In fact on the day of the inspection one of the residents had an appointment with the optician later that afternoon. He kept reminding the staff of his appointment so it was very apparent that the residents are made aware of when their appointments are. DS0000027888.V326784.R01.S.doc Version 5.2 Page 16 If any of the residents need to attend hospital appointments then the manager always ensures that these appointments are kept, and that a member of staff always accompanies the resident. It was apparent that staff provide sensitive and flexible personal support to maximise the privacy, dignity, independence and control that residents have over their lives. Times for getting up/going to bed, meals and other activities are flexible and in accordance with the wishes of the each resident. The manager and staff ensure that the administration of medication is delivered in accordance with the home’s policy and procedures, and the records were found to be in good order. Staff have undertaken the necessary training for the safe administration of medication. The condition of residents taking medication is monitored and the GP is called in if there are any concerns about changes in condition which may be as a result of medication. Residents and their families are clear about how ageing, illness and death will be handled by the care, and can be assured that such events are handled with kindness, comfort and dignity and that their wishes will be observed by the manager and staff. DS0000027888.V326784.R01.S.doc Version 5.2 Page 17 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 and 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users feel that their views are listened to and acted upon and that they are protected from abuse, neglect and self-harm. EVIDENCE: There is a complaints procedure in accordance with the requirements of the Care Home Regulations, and a copy of this procedure has been produced in a simple pictorial format, a copy of which is in each resident’s bedroom. Following discussions with the residents the inspector is confident that the manager and staff will listen to, and act upon, the views and concerns of residents and others, before being allowed to develop into problems and formal complaints. Residents, if they wish, can make a complaint one-to-one with a staff member of their choice, and/or are helped to access an independent advocate. A record of all complaints is kept and the complaints log was viewed as part of the inspection process and this was found to be in order. From viewing training records and discussions with staff it was evident that current staff have received training in adult protection, and there is an effective policy and procedure on adult protection which is known to staff. At the time of the inspection there has not been any adult protection issues. DS0000027888.V326784.R01.S.doc Version 5.2 Page 18 Physical and verbal aggression by a resident is understood and dealt with appropriately, and physical intervention would be used only as a last resort by trained staff in accordance with Department of Health guidance. Should any form of restraint be necessary, the manager and her staff would ensure that this protected the rights and best interests of the resident, and would be minimum consistent with safety. They would also ensure that appropriate records were maintained. The home’s policies and practices regarding residents’ money and financial affairs ensure that they can access their personal financial records, and that money and valuables are safely stored. DS0000027888.V326784.R01.S.doc Version 5.2 Page 19 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, 27, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can feel confident that they can live in a homely, comfortable and safe environment which is well maintained, clean and hygienic and that their bedrooms can be personalised to suit their individual needs and choices. EVIDENCE: The inspector undertook a tour of the home accompanied by two of the residents who were very anxious to show the inspector the communal rooms and the bedrooms. There is a lounge/dining room to the front of the home, and a lounge and a conservatory to the rear. The rear lounge is used as a quiet lounge if necessary. The kitchen was clean and food kept appropriately in the fridge/freezer. There is a utility room where staff and residents are able to do the laundry. The COSSH cupboard is also kept in the utility room and this was locked. DS0000027888.V326784.R01.S.doc Version 5.2 Page 20 All of the bedrooms have been decorated and furnished to a good standard and it was evident that residents are encouraged to personalise their bedrooms in accordance with their own needs and choices. The two residents took great pleasure in showing me their bedrooms where they had hi fi’s, televisions, DVD’s, books, certificates of achievement and jigsaw puzzles. The toilets and bathroom were clean and there was toilet paper, soap and towels. The rear garden was well maintained and there is a patio which is used by residents when the weather permits. The home was compliant with fire regulations and the fire extinguishers had recently been inspected and found to be in good order. It was evident from discussions and from observations that respect for residents’ privacy is fundamentally important, including the freedom to come and go within a risk assessment framework, and receive guests as they wish. The manager and staff are very au fait with the procedures to be taken in the event of a fire, and monthly fire drills are undertaken to ensure that residents remain aware of these procedures. All rooms are fitted with a smoke alarm and these are checked on a regular basis. Because one of the residents has a slight hearing problem a loud horn is sounded in the event of a fire. The manager has also made contingency plans with a local hotel in the event of the need to evacuate the home. The manager lives on the premises and has her own accommodation on the second floor. DS0000027888.V326784.R01.S.doc Version 5.2 Page 21 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 and 36 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported by staff who have, and are receiving training, are supervised and have been recruited through a robust recruitment policy and practice. Staff are also clear as to their roles and responsibilities. EVIDENCE: As part of the inspection process all of the current staff files were viewed and were found to be in good order with the necessary two references, enhanced criminal records bureau disclosure, application forms, interview notes, supervision contract and employment contract. Staff have received induction training, and are also qualified to NVQ level 2. All staff are given a copy of the General Social Care Council’s code of conduct. Ongoing training is available and includes adult protection, effective communication, health and safety, fire safety, medication administration and food hygiene. Any other training is provided as identified to meet changing needs of residents. Staff are receiving regular supervision which is being documented. DS0000027888.V326784.R01.S.doc Version 5.2 Page 22 It was very apparent that the residents have a very good, open relationship with both the manager and her staff. The manager and staff are accessible and approachable; good listeners and communicators, reliable and honest; interested and motivated and competent to carry out the tasks required of them. Staff are clear about their own and others’ roles and responsibilities, and understand and implement the home’s policies and procedures in promoting the main aims of the home. DS0000027888.V326784.R01.S.doc Version 5.2 Page 23 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 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users do benefit from a well run home, and can be confident that their views underpin self-monitoring and development by the home. The rights and best interests of residents are safeguarded by the homes policies, procedures and record keeping. EVIDENCE: The registered manager has the necessary management qualifications and is also an RGN. She is highly competent to run the home and meets its stated aims and objectives. The manager demonstrates a sound knowledge of both strategic and financial planning and review and provides effective management of the service. DS0000027888.V326784.R01.S.doc Version 5.2 Page 24 It was evident that the manager communicates a clear sense of direction, and was able to demonstrate an up to date knowledge of legislation. The manager ensures that the policies and procedures are reviewed and updated on a regular basis and that staff follow these policies and procedures. From talking to the residents and staff it was evident that the ethos of the home is open and transparent and that the views of residents and staff are listened to and valued. Insurance cover is in place which ensures that the home is well able to fully meet any loss or legal liabilities. The home has very efficient systems to ensure effective safeguarding and management of individual’s money including record keeping. Record keeping is of a high standard and records are kept securely. There is full and clearly written recording of all safety checks and there is no evidence of a failure to comply with other legislation. The manager proactively consults other experts and agencies about health and safety issues. There is a good understanding of risk assessments and this is taken into account in the operation of the home. It was also evident from discussions with the residents and staff that they are always very involved in the day to day running of the home, and that their views are paramount. Clearly the home is operated for the benefit of the residents and they clearly see this as their home. Feedback is actively sought from residents about the services provided, and relatives and other visitors to the home are requested to make their views known to the manager and staff. The manager ensures, so far as is reasonably practicable, the health, safety and welfare of residents and staff. DS0000027888.V326784.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 4 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 4 3 LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 3 4 4 4 X X 4 X DS0000027888.V326784.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000027888.V326784.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 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. 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