Inspection on 21/11/06 for Ravensknowle Road

This inspection was carried out on 21st November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ravensknowle Road 01/10/07

Ravensknowle Road 25/01/06

Ravensknowle Road 13/10/05

Ravensknowle Road 08/03/05

Ravensknowle Road 17/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Ravensknowle Road 128 Ravensknowle Road Dalton Huddersfield West Yorkshire HD5 8DN Lead Inspector Alison McCabe Key Unannounced Inspection 21st November 2006 1:35pm Ravensknowle Road DS0000026327.V313900.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 Ravensknowle Road DS0000026327.V313900.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. Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ravensknowle Road Address 128 Ravensknowle Road Dalton Huddersfield West Yorkshire HD5 8DN 01484 536080 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) Bridgewood Trust Limited Ms Mary Catherine Monaghan Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 Brief Description of the Service: Ravensknowle Road is a care home providing personal care and accommodation for eight adults with learning disabilities. It is operated by the Bridgewood Trust, a voluntary organisation that provides a range of services to adults with learning disabilities. The home is situated in the Dalton area of Huddersfield, adjacent to a park and a short distance from shops and community facilities. There is a bus route within close proximity and Huddersfield town centre is a ten minute drive away. The home consists of an adapted detached property built over three floors with a stair lift between the ground and first floor and ramped access to the front door. All the bedrooms in the home are for single occupancy, one of which has ensuite facilities. The home has a garden and there is a car park to the front of the building. The current scale of charges at this home is £341.01 - £453.54. All service users contribute towards transport costs. The service provider ensures that information about the service is available to prospective and current service users by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this key inspection, a site visit was conducted at Ravensknowle Road by one inspector between the hours of 1.35pm and 6.45pm. In addition to the site visit, information used to inform the inspection includes notifications received from the home about any accidents, incidents or events that affect the well being of service users; provider monthly visit reports submitted to the Commission for Social Care Inspection (CSCI); the pre-inspection questionnaire submitted to CSCI prior to the site visit, and completed questionnaires from service users, relatives and visiting professionals. Questionnaires were sent to eight service users, 8 have been returned; two visiting professionals, 0 have been returned; eight relatives, 4 have been returned; four GPs, 1 has been returned. Comments and feedback have been included within the main body of this report, although the general feedback has been positive with most respondents expressing general satisfaction with the service provided at Ravensknowle Road. One respondent stated, “it could be better”. As part of the site visit, the inspector had the opportunity to talk to four service users, two members of staff and the Residential Services Manager. Communal areas of the home were seen and two service users’ bedrooms. Records relating to service users, staff training and staff rotas were examined and the medication was seen. The inspector also had the opportunity to observe care practice. What the service does well: Before service users move into the home, their needs are properly assessed. Good arrangements are made for service users to spend time at the home and meet other service users and staff before moving into the home. Staff empower and support service users to make decisions about their own lives and take reasonable risks. Good opportunities are offered to service users to participate in a variety of activities, both in the home and in the community. Staff offer good support to service users to enable them to maintain contact with their families and friends. Good food is provided. Service users are supported to have their health and personal care needs met. Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 6 The home has a clear complaints procedure and service users know how to use this. Service users live in a clean and comfortable environment. Staff have positive relationships with the service users at the home. Staff receive training relevant to the service they are providing. Recruitment practice at this home is good. All the required checks on staff are carried out before they work with service users. Medicine management is good. Service users benefit from living in a well run home with an effective staff team. There are good policies and procedures in place to protect service users from harm or abuse. 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. Ravensknowle Road DS0000026327.V313900.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 Ravensknowle Road DS0000026327.V313900.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most service users were given sufficient information about Ravensknowle Road to enable them to make an informed choice about whether or not to live there. Service users’ needs are assessed prior to them moving into the home. EVIDENCE: Of eight service users living at Ravensknowle Road, seven responded in a survey from the Commission for Social Care Inspection (CSCI) that they were asked if they wanted to move into the home. Seven also indicated that they had received enough information about the home to enable them to decide if it was the right place for them. One service user indicated that they had not been asked if they wanted to move into the home and had not received sufficient information about the home. Some of the comments received from service users in response to the question of whether they were asked if they wanted to live at the home are: “I am pleased that I moved here”, “I wish I could go home at weekends”, “I had a tea visit and liked it”, “I had a visit but not enough information”. Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 9 Records relating to two service users were examined as part of the site visit. There was evidence in both files that service users’ needs had been assessed prior to them moving into the home. There have been no admissions to the home since the last inspection visit. Ravensknowle Road DS0000026327.V313900.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): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual care plans do not contain sufficient detail. Service users are supported to take reasonable risks. Staff are good at empowering and supporting service users to make decisions and choices about their lives. EVIDENCE: Two service user care plans were examined. Some of the information was clear and detailed, however a number of gaps were identified and some information was vague and unclear. For example, regarding a service user’s healthcare needs, an entry of “needs staff to take to all appointments” was noted. There was no further information about specific healthcare needs and how staff should support the service user to have these needs met. In the records examined, no information was available in the care plans about Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 11 individuals’ social needs. This must be added. A keyworker system is in place, and keyworkers are responsible for ensuring service users’ care plans, risk assessments etc are up to date in addition to arranging service user reviews. A comment received from a relative suggests that a service user had had a number of changes in keyworker and did not currently have a keyworker. The Residential Services Manager has explained that, due to maternity leave, there had been some changes in allocated keyworkers. Residents’ meeting minutes showed that service users are asked whether they are happy with their allocated keyworkers and this is positive. There was evidence of regular reviews and of service users being involved in this process. Service users are supported to complete a satisfaction questionnaire prior to their review and this is good practice. However, there was no evidence that issues or concerns raised by a service user in the questionnaire prior to his review were discussed, recorded or any action taken to resolve them. A record of agreed goals for individuals was seen in the records. More care needs to be taken to ensure the goals are meaningful, progress monitored and new goals agreed with the service user. A service user’s records showed that he had had the same goal since October 2004, had been achieving the goal weekly since March 2006, however it was not recorded as having been achieved until October 2006. Service users are supported to take reasonable risks, and there was evidence that risks had been appropriately assessed, and agreed actions to minimize risks were recorded. There was evidence that risk assessments are reviewed regularly and updated where necessary. Service users are supported to make decisions about their lives. Through discussion with staff and examination of records there was evidence that service users are provided with information and support to enable them to make decisions about their lives. Staff have worked hard to support an individual to maintain and increase their independence whilst keeping safe. Some service users are supported to manage their own finances. Resident meeting minutes demonstrated that service users are consulted about holidays, birthday celebrations, trips etc. Ravensknowle Road DS0000026327.V313900.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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are enabled to lead fulfilling, active lifestyles both in the home and outside of the home. Staff are good at supporting service users to maintain relationships with friends and family. The food provided at this home is of good quality and is healthy; service users enjoy the meals provided. EVIDENCE: Service users attend a variety of daytime activities, including college, work placements and day services. Service users spoken to confirmed this and evidence of this was seen in the records examined. A range of community Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 13 based activities are available to service users, both together as a group and individually. All service users who completed surveys as part of the key inspection stated that they could choose what they wanted to do during the day, evening and weekend. Comments received include (regarding choice of evening activities) “depending on staff and what is happening”, “I don’t always like going to places but am made to go”. This was discussed with staff on duty who explained that, on occasions, there are not sufficient staff on duty to enable particular individuals to stay at home if they would rather not go out to the arranged evening activity. Whilst it is acknowledged that this may sometimes be the case, it is recommended that a record be kept of such occasions to enable staff to monitor whether the service user’s needs are being met consistently or additional support is required. The home has its own transport and all service users contribute to this. Service users have enjoyed a variety of holidays and short breaks since the last inspection. A service user said she had enjoyed going on holiday to Ireland with her family. Another service user went to Australia with her family and said she had enjoyed this trip. Four relatives returned surveys as part of the inspection, although only three had been completed. All indicated that they were made to feel welcome at the home and could visit their relative in private. Two indicated that they were kept informed of important matters affecting their relative and said they were consulted about their relative’s care. One respondent indicated that this was sometimes the case. It was noted in the records examined that a list of dates of family and friends’ birthdays had been included, however there was no evidence that service users had been supported to send cards or gifts for these occasions. The registered person should look in to this. Through discussion with staff and some service users, it was evident that service users are given opportunities to develop and maintain relationships with people of their choice. Appropriate guidance and support is given to help the service users make appropriate decisions. Through discussion with service users, staff and observation of practice, it was evident that, generally, service users are supported to be as independent as possible and that their rights and responsibilities are recognised. Staff were observed to offer choices to service users and to ask permission before entering service users’ bedrooms. Staff were observed to talk to and interact with service users, not exclusively with each other, generally in a respectful and appropriate manner. Service users’ responsibilities for housekeeping tasks are agreed in residents’ meetings and recorded; evidence of this was seen in meeting minutes. A rota of agreed tasks is displayed in the kitchen for service users’ reference. Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 14 Good food is provided at this home. All service users spoken to said that they enjoyed the food. A service user said, “All the staff are good at cooking”. On the day of inspection, the evening meal was fresh salmon, new potatoes and a variety of vegetables. Fruit, yoghurt or chocolate mousse was available for pudding. The meal was well presented and looked appetising. Service users explained that staff cook the evening meal, although service users take it in turns to do food shopping with staff. Service users confirmed that they choose what is on the menu. A good selection of fresh food was available in the home. The menus submitted with the pre-inspection questionnaire indicate that a varied diet is offered. However, a record of fruit and vegetables included with meals must be included so that it is demonstrated that a balanced diet is offered. Ravensknowle Road DS0000026327.V313900.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users’ personal and healthcare needs are met, although further detail about these needs must be included in the individual care plans. Medicine management is generally good at this home. EVIDENCE: Service users living at Ravensknowle Road require very little personal support, however for those that do, there must be clearer information within the individual care plans setting out individuals’ preferred routines and support required. Service users looked well cared for and said that they choose their own clothes with the necessary support from staff. There was evidence in individuals’ records that service users are supported to attend health care appointments; a service user was supported to go for a flu jab on the day of the site visit. Clearer information about how to meet individuals’ healthcare needs must be included in the care plans. For example, information regarding individuals’ requirements in respect of eczema, Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 16 continence, epilepsy etc must be detailed. There was good information in a service user’s record that they had been consulted about their medication and had been supported to make a decision about the most appropriate way of taking their medication. This is good practice. Feedback from a GP indicated that staff demonstrate a clear understanding of the care needs of service users, patients can always be seen in private at the home and that the home communicates clearly and works in partnership with the GP. All medicines checked were found to correspond with the stock balances recorded on the MAR (Medication Administration Record) sheets. Clear protocols about as required (prn) medication were available for individuals. Staff were reminded at the time of the visit that they must label eye drops with the date of opening, as these have to be discarded after twenty-eight days, and that medication stored in the fridge must be kept in a locked box. These matters were addressed at the time of the visit therefore a requirement has not been made. One GP completed a survey as part of the inspection and stated that they were satisfied that service users’ medication was appropriately managed in the home. Ravensknowle Road DS0000026327.V313900.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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good procedures are in place to enable service users to discuss any concerns or complaints. Good policies, procedures and practice protect service users at this home from abuse or harm. EVIDENCE: The pre-inspection questionnaire indicates that no complaints have been received at the home in the last twelve months. All service users and relatives stated, on the survey completed as part of the inspection, that they knew how to make a complaint and service users know who to speak to if they are not happy. A clear complaints procedure is in place and residents’ meeting minutes showed that the procedure is discussed on a regular basis. Adult protection procedures are in place in addition to the Kirklees multiagency guidelines. All staff except one have received training in adult protection; evidence of this was seen in training records. A number of adult protection matters have arisen since the last inspection. The home have notified the appropriate people including the Commission for Social Care Inspection, Kirklees Social Services and relatives and taken the appropriate action in order to protect service users. Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean and comfortable home. EVIDENCE: All communal areas of the home and two service users’ bedrooms were seen during the site visit. All areas were clean, free from unpleasant odour and comfortably furnished. All service users indicated, on the survey completed as part of the inspection, that the home is always clean and fresh. The bathroom on the ground floor does not have any heating and service users said that they found it very cold. Staff explained that this had not previously been an issue as the boiler had been located in the bathroom keeping it very warm. The boiler has, however, been replaced and moved from the bathroom leaving the bathroom cold. A requirement has been made that adequate heating be installed in this bathroom. Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 19 The laundry is based in the cellar and is equipped with a washing machine with a sluicing facility; there is a domestic tumble drier. Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have positive relationships with service users. Relevant training is provided to staff. An effective staff team supports service users although a review of the numbers of staff available should be undertaken. Staff recruitment practice and procedures at this home are good. EVIDENCE: Service users appear to have positive relationships with staff. All service users spoken to said that they liked the staff and that they were kind to them. All eight service users responded on the CSCI survey that the staff treated them well and seven indicated that staff listen and act upon what they say. Staff spoken to demonstrated a good understanding of the needs of the service users. Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 21 There are three care staff and a registered manager at the home. Two of the care staff have achieved NVQ level two in care and one has almost completed NVQ level three. All the care staff have completed the Learning Disabilities Award Framework induction and foundation training. Staff training records submitted with the pre-inspection questionnaire show that all staff have attended a good range of relevant training in 2006. This includes fire safety, first aid, epilepsy, autism/aspergers, moving and handling, abuse, medication administration. A comprehensive training and development programme is in place and staff reported that their training needs are discussed in supervision with the manager. The pre- inspection questionnaire indicates that no new staff have commenced work at the home since the last inspection; staff on duty confirmed this at the time of the site visit. Therefore, staff recruitment records were not examined on this occasion as they were found to be in good order at the last inspection. Whilst there is an effective staff team at the home, one relative has indicated on the survey to the CSCI that there are not sufficient numbers of staff on duty and one has indicated that there are sometimes insufficient numbers of staff on duty. It is recommended that the staffing levels be reviewed taking into account the level of supervision required by each service user. Staff on duty at the time of the visit said that, in their opinion, there was usually enough staff to meet the needs of all the service users. They did, however, acknowledge that, on some occasions, a service user was persuaded to go out as he could not be left unsupervised at the home and staff were going out with the remaining service users. It is positive that there has been no staff turnover since the last inspection and that service users receive care from staff that they know well. There was evidence in the records that regular staff meetings take place. Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a well run home. Good quality assurance systems are in place at this home, although clearer evidencing of action taken to improve quality would progress practice in this area. The home is maintained in line with safe working practices. EVIDENCE: It was reported by staff on duty that the registered manager has almost completed her NVQ level 4 in care and management. The manager holds an NVQ level 3 in care and has significant management experience within the Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 23 Bridgewood Trust. Training records demonstrate that the manager regularly attends training to update her knowledge and skills. These include (since the last inspection) home managers’ fire training, medication administration, first aid, supervisory skills and infection control. The organisation uses the ISO 9000 quality assurance system. In addition to this formal system, feedback is sought from service users through residents’ meetings and service user questionnaires that are completed prior to individuals’ annual reviews. As previously mentioned in this report, it is not always evident that feedback provided by service users in the questionnaire is acted upon and this must be addressed. Monthly unannounced visits are conducted by the service manager in line with Regulation 26 of the Care Homes Regulations 2001, and a report is produced and sent to the Commission for Social Care Inspection (CSCI). The pre-inspection questionnaire indicates that maintenance of equipment is conducted at the required intervals. Records regarding health and safety matters were examined during the site visit and found to be in good order. Fire alarm tests and drills are undertaken at the recommended frequency and there was evidence in the residents’ meeting minutes that the fire procedure is discussed on a regular basis. Work place risk assessments are carried out and comprehensive policies and procedures for the health and safety of service users and staff are in place. Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 3 X 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 3 X 3 X 2 X X 3 X Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 Requirement The registered person shall prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. 15/12/05 and 28/02/06 unmet. Heating must be provided in the ground floor bathroom. The registered person must, so far as practicable, take into account service users’ wishes and feelings (as expressed in satisfaction questionnaires) regarding their care, health and welfare. Timescale for action 15/02/07 2. 3. YA24 YA39 23(2)p 12(3) 31/01/07 15/01/07 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. Refer to Standard YA23 YA37 Good Practice Recommendations All staff should attend adult protection training. The home manager should achieve NVQ level 4 in care and management as soon as possible. DS0000026327.V313900.R01.S.doc Version 5.2 Page 26 Ravensknowle Road Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Ravensknowle Road DS0000026327.V313900.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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