Inspection on 10/07/06 for Pines

This inspection was carried out on 10th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pines 11/11/08

Pines 27/11/07

Pines 22/05/07

Pines 20/01/06

Pines 26/07/05

Pines 07/02/05

Pines 06/09/04

Pines 03/03/04

Pines 06/02/03

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

CARE HOME ADULTS 18-65 296 Old Worting Road (Pines) Basingstoke Hampshire RG22 6NX Lead Inspector Mrs Pat Hibberd Unannounced Inspection 10th July 2006 09:00 296 Old Worting Road (Pines) DS0000012310.V297259.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 296 Old Worting Road (Pines) DS0000012310.V297259.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. 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 296 Old Worting Road (Pines) Address Basingstoke Hampshire RG22 6NX 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) 01256 333 686 www.together-uk.org Together Working for Wellbeing Mrs Yvonne Michelle Rabson Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th January 2006 Brief Description of the Service: 296 Old Worting Road opened in 2004 and is a large property set in a quiet suburban street. It is within easy reach of the local facilities with a bus route to the centre of Basingstoke. Together is the registered provider and the registered manager is Yvonne Rabson. The home is registered to provide care and accommodation to seven service users who have mental health issues. The home comprises of seven single bedrooms, one sitting room, and kitchen/diner and laundry facilities. The garden is well maintained, providing additional recreational space. 296 Old Worting Road encourages service users to retain their own privacy and endeavours to support them in reaching their own personal goals. Fees are paid through a block contract with the Primary Care Trust with service users contributions varying dependent on income. 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection for the inspection year 2006/2007. All key standards were inspected on this occasion. The site visit to the Home inspection took place over 5 hours and the inspector was able to tour the home and garden. Discussions were held with five of the seven service users accommodated, the Home’s deputy manager, one relief worker and one permanent staff member. Two service users’ care plans were viewed. A pre inspection questionnaire completed by the Home’s deputy manager and received prior to the inspection further contributed to this report. Three service user comment cards were also received by the commission of which views expressed as to the service provided by the Home are also included within this report. There were five areas of improvement identified of which details can be found in the main body of the report. What the service does well: What has improved since the last inspection? 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 6 At the last inspection some individuals’ needs had changed and it was identified that a re-assessment would be beneficial to ensure the home can still meet the needs of all service users’ accommodated. This work has begun with a system in place to ensure that needs are regularly reviewed. 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. 296 Old Worting Road (Pines) DS0000012310.V297259.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 296 Old Worting Road (Pines) DS0000012310.V297259.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 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 adequate. This judgement has been made using available evidence including a visit to this service. There are clear care planning systems in place ensuring prospective service users needs and aspirations are assessed, although the lack of risk assessments of service users needs in the event of a fire evacuation place service users at risk. EVIDENCE: There have been no new admissions to the Home since the last inspection. In the event of a vacancy in the Home there is a pre admission process. This includes service users only being admitted following an assessment of their needs by the Home in conjunction with all relevant professionals. The service user is central to all care planning and decision-making. For service user’s referred through Social Services or Health Services a copy of their assessment would be obtained alongside a copy of their Care Programme Approach (CPA) assessment. The assessments ensure service users mental health needs and support required to meet those needs and by whom are considered before a placement is offered. 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 9 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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are clear care planning and risk assessment systems in place which service users are fully involved with. Staff have the information required to meet the needs of service users and enable service users to make decisions about their lives. EVIDENCE: At the last two inspections it was identified and discussed with the manager that all areas of service user’s assessment of need should be completed to show all aspects of a person’s life has been assessed. Two files viewed indicated that the two service users have had a re assessment of their needs and aspirations for the future were documented including planning for one service user to go into to semi independent living. The deputy manager indicated that all service users accommodated are currently undergoing a process of reassessment. Two service users spoken to indicated that they were involved in their care plan. They considered that staff listened to their views and provided good support. They were particularly positive about 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 10 staff’s flexibility during times when the support they needed increased due to physical and, or mental health deterioration. Staff spoken to were aware of the information held in files and were able to describe care and support needs for service users accommodated. From the two service user files viewed it was further evident that they had been compiled in conjunction with other professionals and the service user and were detailed. For example for one individual whose physical and mental health is deteriorating the care plan included details of support required from staff and professionals to ensure they maintained a level of independence within a risk management framework of care. Care plans viewed further included details of positive, planned interventions including communication techniques and support required to meet individuals ‘ mental health needs. In discussion with the deputy manager and two staff it was clear that the care plans and guidelines are referred to on a daily basis alongside good systems of communication that have been developed to continually inform the reviewing process. Communication systems that includes shift “handovers”, completion of daily records and informal discussions. Staff confirmed that they had attended a range of training including complex needs, recovery model, drugs and alcohol awareness, boundaries and abuse. From discussion with staff it was clear they had a good understanding of individual’s’ needs. They were seen to interact appropriately offering service user’s support to make choices and reach decisions they were considering. 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have opportunities to participate in activities of their choice ensuring their rights are respected and responsibilities recognised in their daily lives to enable continued independence. Service users receive good support from families and friends. Service users are offered plenty of fresh food with lots of choices to enable a balanced and healthy diet EVIDENCE: Service users accommodated live varied lifestyles with the majority independently accessing the community to attend local groups and activities if they so wish .One service user has a voluntary job and from discussions with staff and documentation viewed receives the support they need. Another service user has recently been to France and regularly visits their family using the train. Some service users were going shopping during the inspection with the Home having an agreed system whereby service users inform staff when they are 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 12 going out and when they have returned. There are bus routes close to the Home. Staff spoken to demonstrated an awareness of the Disability Discrimination Act and the rights of individuals. Service users have regular contact with families and friends who are welcome to visit the Home with the service user’s agreement. Information relating to family and friends was detailed in care plans. There is a timetable in the dining area showing who is responsible for what jobs around the Home. Service users said they are treated with respect and staff would only come into their bedrooms if invited. The menu was seen and there are two choices with a tick to indicate what choice has been made. On the day of the inspection plenty of fresh fruit and vegetables were available. Service users prepare their own breakfast and lunch and staff prepare the evening meal. One service user said they would make themselves something if they didn’t like what was on the menu. Risk assessments were seen in some service users’ files as to the use of appliances in the kitchen. 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported with their own personal and health care needs, with appropriate assistance from relevant professionals. The medication system in the Home is well managed, which protects service users. EVIDENCE: Two files viewed indicated that health care needs are met, with clear information on each service user’s specific needs. Where required staff support service users to attend appointments although the majority are independent. One service user has physical health needs and from discussion with the individual was being appropriately supported by staff. A stair lift gives the individual access to the first floor where the lounge is located and the garden can accessed by the side door. Some of the service users are over 65 years of age and have some health issues that have resulted in staff being required to provide personal care. In discussion with the deputy manager she indicated that whilst care plans gave guidance to staff as to the support required the Organisation did not have a policy or procedure in relation to personal care. It was agreed that the deputy would raise the issue in the next area manager’s meeting and request that a policy and procedure be devised. In the interim staff in the Home confirmed 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 14 that they had good information on which to provide appropriate personal care to individual’s who needed it. Health needs are closely monitored, with the support of the Community Mental health Team of which detailed correspondence and guidance were seen in files viewed. Files viewed further confirmed that service users have access to a local GP, community dental and chiropody services, and optician. The Home has a copy of the Royal Pharmaceutical Society Guidelines and a medication policy and procedure of which staff spoken to were aware of and had access to. Medication records were viewed and were up to date with medication appropriately stored. One staff member explained that the senior staff member on duty would hold the key to the medication cupboard with two staff administering medication. From observations of staff administering medication the process endeavoured to ensure individuals dignity and privacy was upheld. All staff are trained in the administration of medication and receive six monthly updates. Care plans viewed detailed guidelines for administering PRN (as required) medication including preventative measures staff need to take prior to administering PRN medication. Staff spoken to were able to explain how the guidelines are put into practice and the importance of ensuring they were aware of how to support an individual and recognise any deterioration in their physical or mental health. One service user self medicates with documentation viewed indicating that the individual is supported to do so by staff who monitor that the medication is taken throughout the week. 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints policy and procedure and alternative systems are in place to ensure that service users concerns are addressed. Staff have a good understanding of adult protection issues, which protects service users from abuse. EVIDENCE: The Home has a complaints procedure. Staff and service users spoken to indicated they were aware of and knew how to use it. One complaint had been made to the Home since the last inspection that had been appropriately dealt with. A complaints book was in place. The Home has all relevant documentation relating to adult protection including a whistle blowing procedure, the adult protection policy and the “No Secrets” guidance. Staff had received training in abuse with one staff member discussing a scenario and how they would respond to a disclosure. One adult protection investigation has taken place since the last inspection that has been addressed and was seen to be appropriately responded to. Finance records for one service user were inspected with all relevant documentation in place. However, in discussion with the deputy manager there is no external audit undertaken by the Organisation regarding the accounting of service users’ personal monies by the staff team. The deputy manager indicated that she would welcome such an audit-taking place and agreed that she would discuss how this could be achieved at the next area management meeting. This will be followed up at the next inspection. 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comfortable, clean, hygienic and safe environment is provided for service users, which meets their needs although a system must be put in place to lessen the risk of cross infection. EVIDENCE: The home is well maintained and suited to the service user’s needs. It is decorated to a standard that creates a comfortable and homely environment. All service users spoken to indicated that the home met their current needs. There is an ongoing maintenance programme in place with the deputy manager indicating that a work sheet is completed and sent to the landlord if works are required to be undertaken. On the day of the inspection the laundry room was locked for health and safety reasons following a leak in the ceiling from faulty pipe work. This had been reported. Service users indicated that they were aware that the room was not accessible. There have been no recent visits from the Statutory Fire Officer or Environmental Health officer. The garden area looked welcoming and had a number of flower baskets. There is an area in which service users were seen to use and indicated they enjoyed. The Home was clean and hygienic and free from offensive odours on the day of inspection. There are ample hand washing facilities and bathrooms and policies and procedures in place relating to the control of infection. The laundry has 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 17 ample facilities and although service users are not currently able to independently use the room they indicated that the facilities normally meet their needs. It was agreed with the deputy manager however, that towels in the bathrooms for use of both staff and service users could encourage cross infection and a system needs to put in place to lessen the possibility. 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 18 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 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good skill mix of well-trained staff to support service users. The relevant recruitment practices in place ensure service users are protected. EVIDENCE: Staff spoken to including a relief worker from another Home within the Organisation demonstrated an excellent understanding of service users’ needs and were observed as being approachable, good listeners and communicators and supportive of service users’ requests throughout the inspection. Service users spoken to further supported this view. Staff indicated that a range of training is provided by the Organisation relevant to the needs of service user’s accommodated. It includes a thorough induction, mental health awareness, hearing voices, challenging behaviour, recovery model, management performance and abuse. Future training planned includes complex needs, boundaries and recruitment and selection. Of the six fulltime and one part time staff members of the team two have achieved National Vocational Qualifications (NVQ) in care and three are working towards NVQ Level three. Two staff spoken to demonstrated an awareness of equality and diversity issues and application to their daily practice. One staff member confirmed that the Home has a policy and procedure addressing diversity and equal opportunities that is covered during induction and addressed during both staff meetings and supervision as required. Staff spoken to said that they have 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 19 a training needs analysis and opportunities to develop their practice with the support of management. The inspector viewed two staff files and all contained training undertaken, a criminal records bureau check, application form, references and a health check. There was also evidence of regular supervision and staff spoken to confirmed this. However, the training records of relief staff employed by the Organisation are not held in the Home unless they are designated relief staff for that specific Home. As a consequence the training of all staff working in the Home at any one time may not be known by the staff and management team. To ensure the staff team have the skill base to support service users accommodated it was agreed that the deputy would raise this in the management area meeting and ensure that training records of all staff regardless of whether they are relief or permanent members of the team are held in the Home and available for inspection. The deputy reassured the inspector that only staff known to service users and who are familiar with their needs would work in the Home. From a discussion held with a relief staff member during the inspection it was evident that they were fully aware of the needs of service users accommodated. 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 20 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 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Leadership provided by the temporary manager is satisfactory ensuring positive outcomes for service users and staff who are involved in the running of the service. The health and safety practices in the home are generally satisfactory although EVIDENCE: The registered manager of the Home Yvonne Rabson is currently seconded to another Home within the Organisation. 296 Old Worting Rd has had a temporary manager in post for four weeks. The commission have recently been advised of this change and will be following up with the Organisation as to what plans they have for the future management of the Home. On the day of the inspection the temporary manager was not on duty. However, from staff and service user feedback they felt supported and that the change in management had not had any major impact on the running of the Home. 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 21 The deputy manager has worked in the Home for a period of time and was available on the day of inspection. In terms of quality assurance systems in place in the Home monthly one to one meetings are held with service users and their key workers to gain the views on the running of the Home. Service users and staff indicated that any issues identified are passed onto the manager for action. There is a continuous monitoring of service users needs with a monthly visit undertaken by senior members of management within the Organisation to ascertain their views as to how their Home is functioning. These visits are recorded and copies are sent to the commission. The deputy manager indicated that the visits provide an opportunity for service users and staff to talk to senior staff within the Organisation. Service users views are further sought through annual questionnaires and this information is then used as part of the annual review of the Home. Views are also sought from staff, relatives and professionals. Staff were aware of the policies and procedures relevant to the Home and that they were kept in the office and accessible at all times. These are regularly reviewed by management to ensure they are kept up to date with legislation with changes discussed during team meetings or, referred to in the daily communications book if required. Two members of the staff team manage health and safety matters in the Home with the manager having overall responsibility. Staff indicated that they have received training in health and safety, moving and handling, first aid, food hygiene and infection control. Documentation relating to the Control Of Substances Hazardous to Health (COSHH) was also available in the Home of which staff indicated they were aware of and referred to. The Home completed a pre inspection questionnaire which indicated that all relevant records and certificates are in place to ensure the environment is safe and secure with service users spoken to indicating that they felt the Home to be safe and were aware of what they should do in the event of a fire. Records viewed confirmed that regular testing of fire appliances takes place on a weekly basis. The accident book was viewed and had been appropriately completed and action taken as necessary. However, although staff demonstrated an awareness of individuals’ needs in the event of an evacuation of the Home there was no documentation to support evidence of the individual risks identified and verbally discussed amongst the staff and management team. The deputy agreed to complete the risk assessments and share with all staff and ensure the assessments were kept under review. An area of improvement identified at the last inspection for all staff to undertake twice yearly fire training has not been achieved and was brought to the attention of the deputy who agreed to address as a matter of urgency. This area of improvement is therefore repeated in this inspection report. 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 22 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 2 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 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 23 YES 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 YA42 Regulation 4(d) Requirement The registered person must ensure all staff receive fire training twice in a twelve-month period. (This requirement is outstanding from the last inspection with a timescale of 20/03/06). Timescale for action 24/07/06 2. YA42 13 4. YA35 18 The registered person must 12/07/06 ensure all service users have an assessment of their needs and related risk assessments are compiled as to what support they require in the event of a fire evacuation in the Home with staff kept informed. The registered person must 24/07/06 ensure training records of all staff employed in the Home are available for inspection. 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 Good Practice Recommendations DS0000012310.V297259.R01.S.doc Version 5.2 Page 24 296 Old Worting Road (Pines) 1. Standard YA18 The registered person must ensure there is a policy and procedure in relation to personal care support needs. This must be shared with staff and kept under review. 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 25 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 296 Old Worting Road (Pines) DS0000012310.V297259.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!