Inspection on 18/09/07 for Red House Lane, 2

This inspection was carried out on 18th September 2007.

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

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

Other inspections for this house

Red House Lane, 2 11/10/06

Red House Lane, 2 24/01/06

Red House Lane, 2 07/07/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Red House Lane, 2 Bexleyheath Kent DA6 8JD Lead Inspector Keith Izzard Unannounced Inspection 18th September 2007 10:00 DS0000062617.V346322.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 DS0000062617.V346322.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. DS0000062617.V346322.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Red House Lane, 2 Address Bexleyheath Kent DA6 8JD 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) 0208 304 9718 redhouselane@mcch.org.uk MCCH Society Ltd vacant post Care Home 2 Category(ies) of Learning disability (2) registration, with number of places DS0000062617.V346322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Through the CSCI inspection process, should the Commission identify the need for the home to register it’s own Manager then the home will be required to do so. 11th October 2006 Date of last inspection Brief Description of the Service: Red House Lane is a purpose refurbished detached bungalow providing long term care for two severely learning disabled people, of either gender, focussing on profound communication problems, sensory impairment, autism and challenging behaviour. The home consists of a large communal lounge, kitchen / diner, bathroom with a toilet and a separate toilet. There are also two large bedrooms, above the minimum required size, a large entrance hall and a small office. There is a garden to the rear and a driveway with garage to one side. The home is well situated for access to all local facilities and amenities and a minibus is provided for transporting the residents. Permanent day staff and two waking night staff are employed who are well qualified and experienced to provide appropriate care and are well supported by the community services of the local Community Learning Disability Team and health services. DS0000062617.V346322.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced inspection was completed over a period of 6.5 hours on 18/09/07. Two members of staff and the new manager assisted the Inspector in a constructive and helpful manner. The inspection included a review of information received about the service, a tour of the premises, an examination of records that are required to be maintained, including care plans, talking to staff members and observing residents’ interaction with members of the staff team. There was a happy and positive atmosphere in the home on the day of inspection and residents appeared well cared for by staff members who were observed to be both caring and professional in their approach with residents. What the service does well: What has improved since the last inspection? A new permanent manager had been appointed who has applied to CSCI to become the Registered Manager for both this home and another small home DS0000062617.V346322.R01.S.doc Version 5.2 Page 6 very nearby. The home has endured the protracted absence of a Registered, or permanent manager. This coupled with a reorganised staff team hopefully now affords a period of stability and consolidation. This was already evident at the time of this inspection. All but one of the requirements and recommendations, made at the previous inspection had either been implemented or are underway. 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. DS0000062617.V346322.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 DS0000062617.V346322.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 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission procedures were in place to comply with these standards and service user needs were assessed. The Statement of Purpose and Service User Guide need updating to reflect management and staffing changes. Contracts have been provided as required for residents. EVIDENCE: Standard 1 Whilst a comprehensive Statement of Purpose and Service User Guide is provided the manager confirmed that he is aware that these documents will need to be updated to reflect the changes of staff and manager for the home. The new manager was appointed in June 2007 and is currently being assessed by CSCI to become the Registered Manager for both this home and another small home very nearby. See Requirement 1 DS0000062617.V346322.R01.S.doc Version 5.2 Page 9 Standard 2 The admission procedures in place complied with this Standard. Evidence of this was seen during an examination of the records relating to both service users. The records showed that there had been good preparation in terms of the transfer arrangements from the previous home and that comprehensive documentation in respect of care plans and risk assessments were in place to support their assessed needs. In response to a previous requirement made at the last inspection the home has further developed individual care plans to reflect all the areas of need listed in Standard 2.3 and show how these needs will be met and the outcomes are reviewed and recorded at each subsequent review meeting. Standard 5 At two previous inspections requirements were made to ensure that the home provides contracts for residents in accordance with the specification set down within this Standard. We were pleased to note that this has now been complied with and the relevant documents are retained on the individual service user care file. DS0000062617.V346322.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 good. This judgement has been made using available evidence including a visit to this service. Risk assessments were comprehensive and updated on a regular basis. Care plans reflected outcomes in terms of how individual needs were to be met. Annual Care/ Life Plans were also up to date and showed that residents were involved and family or representatives and professionals involved had been invited. However, care plans must be reviewed on a six monthly basis. Residents were involved in decisions about them, supported to be as independent as possible and records about them were handled appropriately to maintain confidentiality. EVIDENCE: Standard 6 DS0000062617.V346322.R01.S.doc Version 5.2 Page 11 Care provided to both residents was tracked. Care plans were well written and were supported by up to date assessment of need. The home has now developed the care plans to reflect all the areas of need listed in Standard 2.3 including how these will be met and the outcomes reviewed and recorded at each subsequent review meeting. See Standard 2 It was evident in the care plans that residents, a relative and an advocate were involved in care planning. However, the resident who has an advocate has no one else to advocate on his behalf and the Inspector was concerned that the involvement of the advocate was largely confined to attendance at review meetings furthermore the manager had been recently informed that the advocate was being withdrawn as the advocacy service could only be involved now when requests were made to address specific issues on a one off basis. This is very regrettable but we are aware of demand outstripping supply generally in this kind of provision for service users. It is important that further efforts be made to provide a replacement advocate for this resident. The manager reported that it is not always possible for care managers and other professionals to attend reviews on a six monthly basis. We advised that provided evidence could be shown that parents and professionals had been notified of a forthcoming review then, should individuals be unable to attend, the manager and key worker of the home should undertake an internal recorded review on a six monthly basis, recording any apologies for absence from invited outside professionals. See Recommendation 1 Standard 7 A staff member interviewed and the manager said they endeavoured to involve residents in making their own decisions, within the limits of their individual communication and comprehension. This is inevitably restricted by the severe communication difficulties of the residents and they depend heavily on staff interpretation and historical knowledge of individual residents likes and dislikes. Staff members were observed communicating with residents and involving them in whatever was going on in a professional and caring manner throughout the inspection, for example choosing drinks and food and what clothes to wear prior to going out. Standard 9 Risk assessments are available in all service user’s care files and are readily available for all bank or agency staff who may be less familiar with service user’s needs and were updated in response to any changes or developments. Any restrictions placed are few and would be for the safety and welfare of service users, for example not leaving the home unaccompanied. Evidence was available from the service user’s records examined that they are enabled DS0000062617.V346322.R01.S.doc Version 5.2 Page 12 to express choice in what they do and staff record these occasions. This has been supported by Speech and Language Therapist involvement with residents to improve their communication skills and staff members attending an intensive interaction course thereby utilising techniques to improve the general quality of life for residents. The home has an unexplained absence procedure and a current photograph of the residents readily available to assist the appropriate authorities in the event of a resident going missing. DS0000062617.V346322.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): 11-17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Attention was given to meeting the leisure and social and personal needs of residents but further development is needed. Meals provided were varied and planned to meet the resident’s choice and preferences, however diet advice was being sought for one resident. EVIDENCE: Standards 11 &12 Evidence was available from both the care files of residents that opportunities are being made available for their personal development. Although, owing to the level of learning and physical disability and associated communication difficulties neither of the residents have been identified as being able to participate in employment or further education via day centres. One resident DS0000062617.V346322.R01.S.doc Version 5.2 Page 14 has specifically communicated his dislike of day centres and in view of this lack of provision, for both residents, it was acknowledged that activities provided for both of them should continue to be carefully recorded and monitored. In a previous inspection a requirement was made that staff should attempt to identify whether any refusals to engage in activities suggested was as a result of challenging behaviour or expressed choice not to participate. This monitoring should be part of structured sensory sessions with aims clearly stated and recorded to assess progress and outcomes. This has been partially introduced, but this must now be fully developed to increase the range of experiences provided for the residents. See Requirement 2 12 (1 b) &16 It was noted previously that two visiting professionals, one from the Speech and Language Therapy department and another from the Sensory Impairment Team have both been involved in the assessment of the residents and in providing staff with advice on how to improve both their communication skills with residents but also in how to expand their involvement in developmental activities. Following a report in June 2006 six specific recommendations were made for both service users, these have been partially addressed but must now be implemented as soon as possible and facilitated by further staff training in “Active Support” and communication training. See Restated Requirement 3 as above Standards 13 &14 The Inspector examined a list of activities for service users that is updated weekly and notes are recorded in the daily diary and staff communication book of those activities that are planned for service users. Valued and fulfilling activities are provided both within the home and via the outings provided. A range of activities is provided for service users including shopping, using a trampoline at a local gym, bowling, swimming walks and trips out locally to pubs and restaurants and for one resident includes home visits to his mum on a weekly basis. In house activities include games, music sessions, sensory activities music TV and videos and supervised domestic activities in accordance with their level of ability and expressed choice. However, staff members are trying to purchase a new more appropriate vehicle, that all staff members can drive, as there has been some criticism that some outings for one resident had been cancelled at short notice if there was not available a member of staff who could drive the existing vehicle. Also, that weekly swimming sessions should be provided at an appropriate facility for one of the residents. See Recommendation 2 Standard 15 One resident is well supported to maintain positive relationships with his mother who is a frequent visitor to the home and he also visits her at the family home once a week. One resident has no family involvement but did DS0000062617.V346322.R01.S.doc Version 5.2 Page 15 have an advocate. As stated in Standard 6 it is very important that this advocacy is replaced for this resident. See Recommendation 1 Standard 16 Residents were enabled to choose their own clothes and hairstyles, when accompanied by staff members on shopping tips. Residents were also supported to choose their own decoration and personal items for their own rooms and to participate, or otherwise in activities of their own choosing. The mother of one resident has personally decorated his room and made a fine job of it. The other resident has been assisted by staff members to create a personalised room that also includes items adapted by the clever use of ordinary items such as wardrobe doors made identifiable by the use of sensory materials, as the resident is blind. Standard 17 Varied and nutritious meals were provided to meet resident preferences and a rota of meals provided was seen over a period of four weeks and a good supply of both fresh and frozen food was seen to be available within the home. The mother of a resident had recently expressed some concerns regarding her son’s diet, the composition of which is being assessed by specialist nurse, to ensure professional advice is available to staff members. See Recommendation 3 DS0000062617.V346322.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): 18-20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs were being met based on assessment of need and with the involvement of the resident. Medicines were safely managed EVIDENCE: Standard 18 Care plans and daily records showed how personal care was provided. Staff spoke with knowledge and confidence about resident’s individual needs and preferences. For example, around times for getting up, going to bed, whether they preferred to lie in, preferences for a bath or a shower and mood indicators. Staff also said that they are sensitive to the need for maintaining privacy and dignity for residents. DS0000062617.V346322.R01.S.doc Version 5.2 Page 17 Standard 19 Both residents were registered with a G.P and a visiting Psychiatrist both Dr’s provided a very positive response to the CSCI questionnaires sent out and it was evident from the records seen by the Inspector that residents were supported to access other health care such as dental, optical, dietician and chiropody speech and language therapy and sensory impairment. Specialist health care was accessed through G.P referral and other support through the local Community Learning Disability Team and a Health Facilitation officer within Bexley Council. Standard 20 Due to the level of disability, service users are not able to self medicate and would not be able to do so without a high degree of risk. Medication is stored in a locked cupboard in the manager’s office. Medication is the responsibility of the designated person in charge on all shifts and only permanent staff that have received training are authorised to administer medication. Both MAR sheets were examined and checked against stored medication and found to be accurate. The administration, receipt recording, handling and disposal of medicines met the Standard. It was acknowledged that two mistakes regarding medication had been the subject of complaints logged by the relative of one resident, and that this had been rectified and both incidents were appropriately notified to CSCI via a Regulation 37 notification, as appropriate. DS0000062617.V346322.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate procedures were in place to ensure complaints were managed and to protect residents from abuse. EVIDENCE: Standard 22 The home had policies and procedures showing how complaints and suspicions or any allegations of abuse would be managed. A system was in place to record complaints made about the service. Two complaints were made to the home both from the mother of one of the residents and both were in respect of medication errors. Both errors were substantiated and appropriate measures taken to prevent a reoccurrence. Both errors were reported promptly to the CSCI as required under regulation 37. No complaints have been received directly by the CSCI although the Inspector was made aware of both the above complaints to the home from the mother via a response to the questionnaire sent out by CSCI prior to the inspection. A concern was also logged about the level of activities provided and the Inspector was made aware of a meeting being set up to address this issue with the mother of the resident in the near future. Standard 23 Any allegations or suspicions of abuse would be referred to the Bexley Community Learning Disability Team (CLDT), for investigation under their DS0000062617.V346322.R01.S.doc Version 5.2 Page 19 Safeguarding Adult protection procedures. No allegations have been made, either to the home or CSCI. Robust systems were in place to safely manage resident’s personal finances and the Inspector examined the ledger and none of the staff acted as appointee for a resident. The Inspector examined the system for dealing with the personal monies of both service users within the home, and found it to be accountable and with a clear audit trail. Additionally, the home is regularly audited via the programme of monthly visits undertaken on Regulation 26 visits. DS0000062617.V346322.R01.S.doc Version 5.2 Page 20 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): 25-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and provided a pleasant and homely environment. Equipment and furnishings provided met the resident’s needs and was maintained and serviced. EVIDENCE: Standard 24 The premises were suited to meeting the needs of the current residents. As residents age or develop mobility problems the suitability of the environment must be monitored to ensure it continued to meet their needs. Standards 25 & 26 One resident’s bedroom was laid out in a personalised way and it was evident that he was encouraged to have personal items in their rooms to reflect their DS0000062617.V346322.R01.S.doc Version 5.2 Page 21 interests and hobbies. This room had recently been decorated very well by the resident’s’ mother and contained both personal possessions and appropriate sensory equipment. Following a recommendation made at the previous inspection the other resident’s bedroom has been improved and developed in order to maximise his personal space in a way that allows self- expression and ease of use with advice given by the social worker for visual impairment from Bexley Social services Department. Standard 27 The bathing and toilet facilities met the needs of the current residents. A dining/ kitchen room containing a washing machine and a lounge was also provided and all facilities are provided on one floor, as the building is a bungalow. Standard 28 Shared spaces were complementary to supplement service user’ individual rooms and the sitting room was appropriately furnished with comfortable chairs a television and radio equipment. Standard 29 As mentioned in Standard 26 a previous recommendation to upgrade one resident’s room and provide sensory equipment was implemented by staff to very good effect. Standard 30 Overall, the home was clean and hygienic on the day of inspection and appropriate infection control and COSH procedures were in place. DS0000062617.V346322.R01.S.doc Version 5.2 Page 22 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. Both the individual and joint support needs of the two residents is provided by staff members, who are competent and have received training. Two specific training needs were identified. Residents are protected by the homes recruitment policies and practice. EVIDENCE: Standard 32 From observations made of care worker practice and the evidence of training provided for staff, the Inspector felt that, overall, there was a good level of skills and experience and that those staff observed had the requisite attitudes and characteristics necessary to adequately support service users. Staff members were observed to be respectful and caring in the way they were relating to service users. It was equally evident that service users were content within their environment and responding positively to any staff interventions, such as assistance with eating or engagement in activities. DS0000062617.V346322.R01.S.doc Version 5.2 Page 23 The home does not currently have the required 50 level of care workers trained to NVQ Level 2, the manager stated that this was being addressed and tat this will be achieved by March 2008 as four members of staff are currently undergoing this training. The Registered Provider must monitor this and report any shortfall to CSCI should this target not be achieved in this timescale. Standard 34 One new member of staff has joined the home from another home from within the organisation the acting manager stated that all necessary checks had therefore been done by the previous home. Evidence was available from the three pro forma recruitment records examined that the home met this Standard. Standard 35 Staff members interviewed, presented as clear about their roles and responsibilities and had received adequate training in accordance with this Standard. A training matrix was seen for both training provided and that scheduled for the future, both met the Standard. However, it was noted that staff members should be provided with updating in “Active Support” and “communication” training. See Standards 11 &12 See Restated Requirement 2 DS0000062617.V346322.R01.S.doc Version 5.2 Page 24 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. The manager runs the home in an open and inclusive manner. Records, policies and procedures showed attention was given to ensuring the safety of residents and others. The quality review survey requires full implementation and publication. EVIDENCE: Standards 37 & 38 DS0000062617.V346322.R01.S.doc Version 5.2 Page 25 The manager has considerable experience and the necessary qualities to provide a good service and has recently applied to be come the registered manager for the home. Staff members interviewed stated that the acting manager is approachable and supportive and would not hesitate to discuss any concerns about the home or the welfare of service users with her. Communication within the home was of a good standard with team meetings held regularly. The acting manager has undertaken training in order to update her own skills and knowledge. Standard 39 The home does now have a quality review system in place to record the views of residents, relatives, advocates and visiting, or involved professionals. However, this has not been implemented and must be as soon as possible, the results published and generally made available, including CSCI. See Requirement 4 The home receives regular monthly visits under Regulation 26 and produces reports as required and submits these to the CSCI. Standard 42 The policies and procedures in place ensured the safety and protection of residents were addressed. A sample of safety records including fire safety were inspected and showed systems and equipment were maintained and regularly serviced. DS0000062617.V346322.R01.S.doc Version 5.2 Page 26 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 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 3 28 3 29 3 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 2 3 X 3 X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 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 DS0000062617.V346322.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 6 Requirement Timescale for action 01/01/08 2. YA11 12 (1) b & 16 3 YA11 12 (10b & 16 4. YA39 24 The Statement of Purpose and Service User Guide must be updated to reflect recent staff changes Structured sensory sessions 01/01/08 must be provided for both residents with goals and outcomes monitored, recorded and reviewed. Similarly, refusals to participate because of challenging behaviour must be recorded. The Registered Person must 01/01/08 ensure that all recommendations made by involved professionals, in respect of developmental activities, are implemented as soon as possible. Restated requirement, previous timescale of 01/01/07 not met. Additionally, training in Active Support and Communication must be provided to facilitate the above The Registered Person must 01/01/08 ensure a system is in place to review and improve the quality of care provided in the home. Outcomes on the quality DS0000062617.V346322.R01.S.doc Version 5.2 Page 28 assurance surveys obtained from relatives/ advocates and involved professionals conducted annually must be published and made available to all including CSCI. Partially Restated Requirement: previous timescales of 1/12/05,01/06/06 01/01/07 not met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations Provided evidence could be shown that parents and professionals had been notified of a forthcoming review then, should individuals be unable to attend, the manager and key worker of the home should undertake an internal recorded review on a six monthly basis, recording any apologies for absence from invited outside professionals. Further efforts should be made to ensure that one resident without family support should receive advocacy visits on a regular basis. Any recommendations arising out of the dietary assessment for one resident should be implemented as soon as possible. 2. YA6 3 YA17 DS0000062617.V346322.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 DS0000062617.V346322.R01.S.doc Version 5.2 Page 30 - 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. 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