Inspection on 31/07/07 for Prospect House Residential Home

This inspection was carried out on 31st July 2007.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Prospect House Residential Home 23/08/06

Prospect House Residential Home 24/01/06

Prospect House Residential Home 02/08/05

Prospect House Residential Home 16/03/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Prospect House Residential Home 4 Prospect Road Cinderford Gloucestershire GL14 2DY Lead Inspector Mr Paul Chapman Key Unannounced Inspection 31/07/2007 09:00 DS0000061957.V336812.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 DS0000061957.V336812.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. DS0000061957.V336812.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Prospect House Residential Home Address 4 Prospect Road Cinderford Gloucestershire GL14 2DY 01594 826246 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) The Silver Rooms (Stroud) Ltd Mr Graham Clive Emery Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (9) of places DS0000061957.V336812.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 2006 Brief Description of the Service: Prospect House is a detached residential care home set in its own spacious grounds near the centre of the town of Cinderford. It is registered for nine adults with Learning Disabilities. All of the bedrooms are single and some have en-suite facilities. On the ground floor there is a lounge, dining room, kitchen, toilet, shower room with a toilet and three bedrooms, one of which has its own entrance. On the first floor there are six bedrooms, a bathroom, toilet, laundry room, storeroom and sleep-in room/office. The cost for living at the home ranges between £500 to £1100 per week. DS0000061957.V336812.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection site visit took place in July 2007. The registered manager was in attendance throughout the visit. The Annual Quality Assurance Assessment was supplied prior to the inspection. Completed surveys were received from relatives of people living at the home. Time was spent observing the care of people and their interactions with staff. Two people living at the home were spoken to at length, and two people’s bedrooms were inspected on their invitation. The care of three people was looked at in depth that included looking at their financial, medication and personal records. Four staff were interviewed about the care they provide. Other records examined included staff files, health and safety information and quality assurance records. What the service does well: What has improved since the last inspection? The home continue to assess the needs of the people they work with and adapt and improve systems to meet people’s needs. An example of this is the DVD based Service User Guide. Care plans provide staff with detailed information that allows them to meet people’s needs consistently. Daily notes have improved and provide the reader with a good level of detail about the person. DS0000061957.V336812.R01.S.doc Version 5.2 Page 6 Person Centred Plans called “Listen to me” workbooks are being developed for each person. Risk assessments have been reviewed and are now more comprehensive minimising potential risks. A member of staff has been given the responsibility for developing plans addressing needs around increased mental and physical frailty and serious illness. The example seen was excellent and person centred. The homes environment continues to improve and provides people with a homely, comfortable and clean environment. 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. DS0000061957.V336812.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 DS0000061957.V336812.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, 4, 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides people with sufficient information and experiences that enable them to make an informed decision about whether they wish to live in the home. People’s needs are assessed before they move into the home minimises the risk of people being admitted whose needs cannot be met. EVIDENCE: The manager has reviewed the home’s Statement of Purpose since the previous inspection. The manager explained that they are currently developing a DVD version of the Service User’s Guide, and showed the inspector the work completed already. This is good practice as the manager has recognised that a written booklet is sometimes not the best format for people with complex needs. It is aimed that this will be finished by October ’07. Two people have been admitted to the home since the previous inspection. Records examined showed that each person’s needs had been assessed by the manager and assessments completed by their funding authorities were present. DS0000061957.V336812.R01.S.doc Version 5.2 Page 9 Before each person decided whether they wished to move into the home they visited and stayed at the home. Information gathered from these visits formed part of the manager’s initial assessment. In the month after each person moved into the home a detailed assessment was completed. In addition to each person visiting the home before admission their parents also visited. The 3 personal files that were examined in detail contained residency contracts with the home. DS0000061957.V336812.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples needs have been assessed and care plans are in place to address the identified needs. People are empowered to make decisions about their lives with the support of the staff when necessary. Resident meetings are in need of review to ensure that all people are empowered to have a voice. Risks to people are assessed, and minimised to enable them to take part in activities safely. EVIDENCE: The previous inspection report made 2 requirements relating to standard 6. The 1st was for the manager of the home to re-assess the needs of each person living in the home. The 2nd requirement was that all of the care plans must comprehensively cover all areas of support for people living in the home. DS0000061957.V336812.R01.S.doc Version 5.2 Page 11 Since the previous inspection was completed the home has purchased a web based computer care system. A staff member spent time with the inspector explaining how the system works. They stated that as a team they are getting used to the system and feel it has been of real benefit to them. The system encompasses needs assessments, care plans, risk assessments, daily notes, medical issues and appointments, and all other significant/relevant information relating to people living in the home. The manager stated that storage of all of this information is secure and in line with the data protection. In addition to all of the information being stored electronically, paper copies are available of all documents. All documents are stored securely in the home. The inspector examined 3 personal files in detail. Each file contained a document called a “listen to me” workbook which was a person centred plan highlighting their likes and dislikes, and their hopes and dreams for the future. The documents seen were thoroughly completed and where possible the person had signed the document agreeing/confirming their input. Whilst examining one of the person centred plans the inspector noted that one person wished to travel to Gloucester alone. The manager explained that due to unavoidable circumstances they had not been able to support the person to achieve this. The manager stated that they were going develop a care plan to address this in the future. When examining other person centred plans it was difficult to assess people’s progress towards meeting their goals. The inspector spoke to the manager about linking the goals for hopes and dreams to the regular monitoring system. The manager stated that this was planned for the future. This becomes a good practice recommendation of this inspection report. All of the files seen provided a good record of peoples interests and the activities they were involved in. Care plans were present in each of the files, the range of areas covered included: • • • • • • • • • Medication Sleep and rest Oral hygiene Bathing Dressing Eating and drinking General health Communication Living skills All of the plans seen clearly identified the goal of the plan and provided staff with detailed information that would allow a consistent approach by the staff team. All of the care plans seen had been reviewed in the past 3 months. As part of the interviews with staff some were asked about care plans and how DS0000061957.V336812.R01.S.doc Version 5.2 Page 12 peoples needs are met. Answers provided evidence that the staff understood the care plans and their importance. Whilst examining one care plan relating to a person going out independently it was noted that there was no reference to when staff should classify the person as missing. By this it is meant that if the person goes to the local town but doesn’t return after 2 hours, is this alright? Or is the person then missing? This was brought to the attention of the manager and must be addressed. All people have a missing person information sheet to be used in cases when a person may be missing. The inspector spent time with two people individually discussing their care with them. Both people stated that they felt their needs were being met and each of them had a key worker. One person spoke in some detail about their care plans and goals of their person centred plan. Both people spoke positively about the support they receive from staff and gave examples of being given choices about what they would like to do. Staff complete daily notes at the end of each shift. The notes examined were detailed and provided good information about activities and other significant information about each person. The manager is aware of the importance of detailed daily notes and provided examples of working with staff to improve the quality of the notes. Staff and people living in the home stated that resident meetings are held every 6 weeks. At a recent meeting people had been asked what activities they would like to complete while colleges and day services were closed. It was decided that every Wednesday a trip or special activity would take place. The inspector discussed with a senior carer how effective these meetings were and suggested different methods that may empower people with communication difficulties. These suggestions included using pictures and maybe allowing the people with communication difficulties to meet separately to discuss what they would like to do. Speaking to staff, people living in the home, as well as daily notes provided evidence that activities were being completed. One person said that “it is much better now and I am able to go out when I want”. A requirement of the previous inspection report was that the manager must complete risk assessments for people completing their day-to-day activities. Examination of risk assessments showed that this had been achieved by the manager and more comprehensive risk assessments were available. The manager must remain aware of the need to complete risk assessments for people completing activities. DS0000061957.V336812.R01.S.doc Version 5.2 Page 13 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, 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People lead active lifestyles with the appropriate staff support that helps them to develop new skills and increase their independence. EVIDENCE: The manager explained that one member of staff has recently completed a college course in the provision of activities in a care setting. This has enabled them to start organising different activities for people. This is still at an early stage and the manager believes this will continue to develop of the coming months. The home has access to 2 vehicles. Speaking with people living in the home, staff and daily notes all provided evidence that the following activities are completed. DS0000061957.V336812.R01.S.doc Version 5.2 Page 14 A good practice recommendation of the previous inspection report was for people to be supported to understand and manage their own finances. As a result of this the staff have been working with people on the recognition coins and notes. This is a regular and structured activity, staff complete record sheets identifying progress on each occasion. Other activities are also completed regularly in the home including art and craft, baking cakes and movie nights. All of the people in the home are asked to be involved in domestic chores to different degrees. People attend college, work on a farm and day services regularly during the week. People are allowed pets in the home. One person has 2 goldfish, while a group of people living in the home have just bought a rabbit. Each person is involved in the care of the rabbit and has been given various tasks to complete in its care. Every Thursday evening the home has an evening at the local pub. People spoken to about this expressed how much they enjoyed it. Other activities that take place regularly include going to the cinema, swimming, evening social clubs, shopping and places on interest. Staff supports peoples’ interests and hobbies. One person is interested in music and has a karaoke machine, drum kit and guitar in his bedroom. Staff have supported all of the people living in the home to go on holiday to Spain this year. Family and friends are welcome to visit the home and staff support people to maintain these relationships if it is required. Staff spoke about supporting one person develop a relationship with a friend. The home have been developing better communication and relationships with families, as part of that the home send out a ¼ly newsletter about the home and hold Christmas and Easter parties. Letters of appreciation from parents were available for examination. The CSCI received a number of completed surveys from relatives, and feedback was positive about the service being delivered in the home. The home has developed a menu based on the known likes and dislikes of the people that live there. Although a menu is prepared both the people living in the home and staff said that other choices were available if someone didn’t want what was on the menu. A good range of meals and snacks were available. Where people have specialised dietary needs these are recorded in their care plans. One person who spoke to the inspector said that the food was DS0000061957.V336812.R01.S.doc Version 5.2 Page 15 nice. People living in the home are involved in food preparation and one person was seen helping to prepare tea. This person spoke to the inspector and said that they enjoy baking and regularly bake cakes with staff for the Sunday tea. People living in the home go to the local supermarket with staff to purchase the items needed for the menu. An idea brought up by people living in the home is having international food nights, meeting minutes showed that they had suggested numerous international dishes and it has been planned that once a month this will be arranged. A good practice recommendation is that the home should continue to develop the menu to enable more choice and moving away from a set menu. DS0000061957.V336812.R01.S.doc Version 5.2 Page 16 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, 21 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Staff are able to meet peoples personal care needs consistently through the detailed care plans. The home make good use of other professionals to meet peoples medical needs. Potential risks to people are minimised through the medication administration in the home. EVIDENCE: People’s personal care needs are addressed in detail within their care plans. The 3 files examined in detail provided detailed evidence of the involvement of other professionals to meet people health and emotional needs where it was appropriate. Notes recorded by staff provided good evidence of the reasons for other professionals input. The home have made good use of other professionals from the local Community Learning Disability Team (CLDT) in reviewing a person’s medication and developing a system for monitoring the person’s behaviour/mood. DS0000061957.V336812.R01.S.doc Version 5.2 Page 17 Medication administration was examined and seen to be managed effectively minimising potential risks to people living in the home. When staff administer medication the manager asks that 2 staff sign to confirm that medication has been administered. This happens on each shift other than the night shift. A good practice recommendation would be for the administration sheet key to be used explaining this. One member of staff is responsible for ensuring that all people living in the home have information about their wishes in relation to ageing and illness. The member of staff is in the process of ensuring all people have a document detailing this information. The example seen was excellent. DS0000061957.V336812.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. The home’s staff have a good awareness of supporting people with communication difficulties if they are unhappy. Records show that people’s finances are appropriately managed. EVIDENCE: The home has a complaints procedure and 1 complaint has been made to the manager by a person living in the home since the previous inspection. Examination of the actions taken by the manager showed them to be appropriate. The CSCI has not received any complaints. As identified previously in this report a number of people in the home have communication difficulties which may make it impossible for them to make a complaint without the support of the staff. The inspector spoke to a number of staff as part of this site visit and asked them what signs they could look out for that showed someone was unhappy, if they weren’t able to say they were unhappy. All staff spoken with were able to give good examples of signs that may show someone is unhappy and the actions they would take to support and protect that person. A selection of peoples’ personal finances was examined. At the time of this site visit all figures were correct and there was detailed records of income and expenditure. DS0000061957.V336812.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, 26, 28, 30 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. The home provides people with a comfortable, homely and safe environment that meets their current needs. EVIDENCE: As part of this inspection a tour of the premises was completed with the registered manager. The outside of the property looks well maintained and the manager explained that an ex-staff member does some gardening with people living in the home. There is a raised garden area where people have been growing onions and strawberries. The garden is equipped with a range of garden furniture and people were using it on the day of this site visit. DS0000061957.V336812.R01.S.doc Version 5.2 Page 20 The lounge is equipped with a television, digital television and a DVD player. The re-decoration of the dining room has been completed, staff stated that people living in the home had chosen the colour scheme. The dining room has a stereo, 2 tables and some comfortable lounge furniture. On the wall of the entrance hall was a picture poster about discrimination/antidiscriminatory practice that a member of staff created as part of a course they completed. A new kitchen was fitted last year. Two bedrooms were looked at on this occasion. Both of the rooms seen were decorated to a good standard and one person spoke about being able to choose the colours, curtains and furniture. The other bedroom seen had a drum kit, guitar and karaoke machine. Both rooms reflected the interests and personalities of the people to whom they belonged. The standard of the accommodation is good and continues to improve as various parts of the home are re-decorated/refurbished. DS0000061957.V336812.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, 34, 35, 36 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Staff receive comprehensive training to meet the needs of people currently living in the home. Potential risks to people living in the home are minimised through the recruitment procedures followed by the manager. EVIDENCE: Each member of the staff team interviewed as part of this visit agreed that training offered to them was comprehensive. Staff commented that there was lots of training available. All staff spoken with stated that they completed an induction when they started at the home. Staff gave examples of the training they have completed, these included: - safeguarding adults, first aid, fire safety, health and safety, behavioural management, risk assessment and Alzheimer’s awareness. In addition to these courses staff spoke about completing different levels of care and management NVQ’s (National Vocational Qualification). To support the comments of the staff training records provided good documentary evidence of the training completed by the team. DS0000061957.V336812.R01.S.doc Version 5.2 Page 22 Staff recruitment records were examined for staff employed at the home since the previous inspection. The files seen showed that the home are following the regulations and therefore minimising potential risks to people in the home. The senior carer on duty explained they are responsible for completing staff supervision sessions with the other senior carer. They explained that currently these sessions take place every 8 to 10 weeks but are aware that they should be completed every 6 weeks. It becomes a good practice recommendation of this inspection report that this is addressed. DS0000061957.V336812.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, 39, 42 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. People benefit from a well run home, managed by a competent manager who promotes a culture of openness, respect and the wellbeing of people living there. A quality assurance system has been implemented that should be enable the manager to monitor and raise standards. Health and safety is well managed and minimises potential risks to people. EVIDENCE: The registered manager has completed the Registered Managers Award and a NVQ level 4 and they have considerable experience working in this field. He ensures that his continuing professional development and has completed ‘Safe Food Safe Business’ course with the local environmental health department. Staff confirmed that the registered manager is open and accessible promoting DS0000061957.V336812.R01.S.doc Version 5.2 Page 24 a person centred approach to care. Records confirm he monitors care practice within the home and challenges poor or misguided practice. Systems are in place to ensure that staff have access to the information they need and the manager monitors this. Record keeping is of a high standard. The Annual Quality Assurance Assessment (AQAA) completed by the registered manager highlights their wish to develop a quality assurance system for the home. A discussion took place about how the manager could achieve this. In the past the manager has asked people to complete questionnaires. The questionnaires should be used again with friends/family and other professionals involved in peoples care. After the site visit of the home had been completed the home purchased a quality assurance package. The manager has started to implement this and has provided the CSCI with a sample of some completed questionnaires. This will be assessed further at the next site visit to ensure that it is being used effectively. Health and safety systems are in place. Sound food hygiene practice is promoted and the home has adopted the safer food, better business model supplied by the local environmental health department. One shortfall was noted with the fridge and freezer temperatures only being recorded once a day, where as good practice says it should be done twice daily. Food in the fridge was being labelled with the date of opening and the temperature being taken of hot food before it is served. All hot water outlets are thermostatically controlled. Water temperatures are recorded for all outlets around the home, although it was brought to the attention of the manager this had not been completed since June. Fire records are well maintained with evidence of regular monitoring of equipment and systems. A fire risk assessment has been completed for the home. Regular fire drills take place for all people and staff. Evidence of regular fire training is in place. Portable appliance testing has been completed. DS0000061957.V336812.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 X 4 3 5 3 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 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 X 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 2 3 3 X 2 X X 2 X DS0000061957.V336812.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 13(4) b Requirement The care plan highlighted in the body of the report must be reviewed to ensure that the person is not put at unnecessary risk. The health and safety checks highlighted in the body of the report must be completed regularly to ensure that people are not put at unnecessary risk. Timescale for action 21/09/07 2. YA42 13(4) 21/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA8 YA36 Good Practice Recommendations The manager and his staff team should monitor people’s goals in their person centred plans. The format for resident meetings should be reviewed to ensure that people with communication difficulties are empowered to be involved. The manager should ensure that all of the staff receive regular supervision. DS0000061957.V336812.R01.S.doc Version 5.2 Page 27 DS0000061957.V336812.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000061957.V336812.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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