Inspection on 07/12/06 for Repton Drive

This inspection was carried out on 7th December 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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Repton Drive 22/11/07

Repton Drive 09/05/06

Repton Drive 28/11/05

Repton Drive 06/09/05

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 Repton Drive 13a Repton Drive Gidea Park Romford Essex RM2 5LP Lead Inspector Jackie Date Key Unannounced Inspection 7th December 2006 09:45 Repton Drive DS0000060783.V325786.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 Repton Drive DS0000060783.V325786.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. Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Repton Drive Address 13a Repton Drive Gidea Park Romford Essex RM2 5LP 01708 750957 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 Avenues Trust Limited *** Post Vacant *** Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2006 Brief Description of the Service: 13a Repton Drive is a six place care home for adults with severe learning and physical disabilities, situated in a residential part of Romford. Opened in December 2004, it is a purpose built bungalow set behind detached houses, a short walk from bus routes into Romford town centre. There are six, single, bedrooms, each with ensuite toilet, shower, and wash hand basin. There is an additional communal shower, and bathroom. The kitchen/diner is domestic in nature, as is the utility room. A conservatory has been added, which is accessed via the lounge, and this adds to the communal space, which was insufficient for six service users. There is parking to the front of the building, and a small enclosed garden to the rear. The home provides 24-hour personal care, with health needs being met by visiting professionals, or staff accompanying service users to outpatient clinics. All areas of the home have full disabled access, and two bedrooms have fixed overhead tracking for specialist hoists. The Avenues Trust, a registered charity, which operates other similar homes in the area and in Kent, runs the home. At the time of the visit two ladies and two men were living at the home. The basic charge per week for each service user is £1485-48. This information was provided at the time of the last visit. Information about the service provided is contained in the service users guide. Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit lasted for about seven hours and took place from 9.45am. The manager, staff and all of the service users were spoken to. All of the rooms in the house were seen and staff, care and other records were checked. Care staff were asked about the care that service users receive, and were also observed carrying out their duties. Due to the level of their disability the service users were not able to give any direct feedback about the care that they receive. Other professionals were contacted and asked for their opinions of the service however no feedback was received. This was a key inspection and all of the key inspection standards were tested. What the service does well: What has improved since the last inspection? There has been a lot of improvement since the last inspection. There is only one requirement from this visit and it is evident that the manager and staff team have been working very hard to improve the service and to meet the requirements from the previous inspection. There is now a new manager in post. The manager and the staff team are working together to develop and improve the service. The organisation are supporting them to do this. The service users are going out more and also doing more in the home. Some parts of the house have been decorated and the rest will be decorated soon. A lot of work has been done to make the garden better and this should be finished soon. All of the health and safety checks are being done and therefore the service users live in a safe home. Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 6 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. Repton Drive DS0000060783.V325786.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 Repton Drive DS0000060783.V325786.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): 2 & 3. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Information is available to enable the staff team to meet service users’ needs. The required information would be gathered on a prospective service user and they and their relatives could spend time in the home to find out what it would be like to live there and to enable the service user to make a choice about living in the home, within their capacity to do so. EVIDENCE: There have not been any new admissions to the home since the last inspection. At the time of that visit a referral had been made for a prospective service user. The paperwork with regard to this individual was examined at that time. A referral form containing basic details had been completed and an assessment made by the referring social worker. In addition to this the manager had completed the organisation’s pre-assessment. This assessment covered all of the required areas and included health, culture and sexuality. In addition to this a copy of the service users care plan had been obtained from his current placement. The manager said that the next step would be to arrange for the individual and their relatives to visit the home. If it were agreed that this person would like to live at the home then a transition plan would be developed. At the time of this visit the manager said that it had been decided that the service was not appropriate for the individual and therefore Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 9 the prospective service user had not been offered a place at the home. Therefore sufficient information would be gathered on a prospective service user to enable their needs to be identified and for a decision to be made about the home’s capacity to meet their assessed needs. Repton Drive DS0000060783.V325786.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 judgment has been made using available evidence including a visit to the service. Service users’ plans contain detailed information so that staff can meet their needs. Risk assessments have been reviewed and therefore contain up to date information about service users needs. EVIDENCE: Each service user has personal planning book covering all of the necessary areas. These include health, finance, communication, domestic skills, activities, mobility, diet, personal care, religion and culture. The plans give details of how each person likes and needs to be supported. The degree to which service users can be involved in the development of the plan is very limited due to their profound learning and communication difficulties. Two care plans were examined. These contained a lot of information about the individuals needs, likes and dislikes. They also had photographs and symbols Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 11 throughout to make them more user friendly From these it was apparent that the staff team know the service users well and that a lot of work has been done to develop person centred plans. The plans clearly described how to support the person and what good support would be like. The plans also clarified the service user’s cultural needs and in one case confirmed that they had no specific dress requirements and that they eat traditional English food but no beef. There was sufficient information available for staff to work with the service users and both plans show that staff know the service users well and that they are working to meet individual needs and to provide a more person centred service. In both cases the personal planning books had been fully completed and information dated and signed as required by the previous inspection. This ensures that all staff have correct and full information about individuals. A new daily recording format has been introduced but daily notes are still limited and therefore do not accurately reflect the service provided. As a result of this the format is going to be changed again and the staff team will be receiving training at the end of January about this. Therefore the timescale for the requirement that daily recordings need to be more specific and detailed and linked to individual plans has been extended to allow for the training to take place and the revised recording system to be implemented. Improved daily recording will ensure of that there is detailed information about each service user, which can be used as part of the review process and to identify ongoing and changing needs. There are risk assessments in place. These identify risks for the service users’ and staff and indicate ways in which the risks can be reduced to enable the service users’ needs to be met as safely as possible. The risk assessments were clear, had been reviewed and were up to date. Repton Drive DS0000060783.V325786.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): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The service users are encouraged and supported to take part in activities both in the home and in local community. The amount and range of activities has increased giving service users a greater variety and choice of what to do. Service users are supported to keep in contact with their relatives and relatives are welcomed at the home. Service users are given meals that meet their needs and individual preferences. Menus contain healthy or low-fat options and service users’ dietary needs are being met. EVIDENCE: Service users have severe disabilities but are encouraged and supported to do as much as they are able for themselves. For example hand over hand support to use a spoon. Each person has a weekly timetable with photographs Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 13 or symbols representing the activity. Feedback from staff was that service users are going out more and are more involved in daily activities in the home. For example baking or putting up Christmas decorations. Service users are also supported to take part in a variety of activities both in the home and in the community. For example going to the theatre, cinema, pubs, local park and shopping. Some service users have aromatherapy and physiotherapy. Staff also said that some of the service users enjoy going to the library and being read to. Some also enjoy watching DVD’s. Art and craft sessions form part of the activities within the house and examples of this were displayed around the home. There were also lots of photographs of service users doing activities and visiting places. For example “our picnic in the park”, a trip to the London Eye and the aquarium. Staff have also started to talk to the service users about holidays in 2007. Therefore the service users are participating in more activities and having a more interesting and fulfilling lifestyle and it was apparent that the staff team want to extend this further and are still looking for other opportunities for service users. All of the service users have contact with their families in varying degrees. One service users’ parents visit regularly and take her out, and another’s sister visits. Families are invited to celebrations at the home and all of the service users have had birthday parties to which family and friends were invited. The Christmas party had been organised for the week after the inspection. Therefore the service users are supported to maintain their contact with their families. There is a varied menu that is developed by staff and it is based on the knowledge of service users likes and dislikes. Photographs have been taken of various foods to assist service users to make choices about what they would like on the menu. Each service users’ plan contained information about their dietary needs and support they need at mealtimes. One plan states “I like a hot drink before I go to bed”. Another says “if I keep picking up cups or play with taps I want a drink, if I hit my chest I want something to eat.” One service user needs food cut into bite size pieces, another has to have the food put on his plate in small amounts at the time and a third needs to be given her food by the staff. The Inspector joined the service users at lunchtime and staff were observed to give each person the support that they needed. Staff were working with one service user to encourage him to use a spoon to feed himself. Records are kept of what each person has to eat. Staff have raised concerns about the weight gained by one of the service users and a referral has been made to the dietician. Unfortunately the service user has still not got an appointment but staff continue to chase this. There is now a two-week menu plan and this contains more fruit and vegetables. Healthy eating options are included in the menu. Meals provided are more balanced and include healthier options as required by the previous inspection. This means that service users receive a nutritious diet that meets their individual needs. Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 14 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 judgment has been made using available evidence including a visit to the service. Service users receive personal care that meets their individual needs and preferences and the staff team support them to get the healthcare that they need. Medication is appropriately administered to service users by staff that have been trained to do this. EVIDENCE: The service users all require a lot of support with their personal care and details of the help that they need and how they prefer to be supported are in their individual plans. The plans also contain information on how to recognise what a service user wants or needs. For example “when I slide down the wheelchair I am either uncomfortable or my pad needs changing”, if I pull at my clothes I would like to take them off or change them”. “If I take my pad and trousers off I need to be changed or want some time alone in my room.” In one persons plan it states how to make that person comfortable at night and includes “I like a book on my bed” and “I like the bathroom light left on as I often wake up in the night”. This shows that the staff team know the service users well and that they aim to provide individuals with a good quality of care Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 15 that meets their needs. On the day of the visit service users seen looked clean and well dressed. Service users’ personal care needs are met. All of the service users go to the local doctor and specialist help is received when needed. Staff take service users to all of their medical appointments. Service users’ files have details of health care issues and show that service users have regular access to health care professionals. As previously stated one of the service users is waiting for an appointment with the dietician and staff are chasing this up. Staff also said that they are concerned because one of the service users is unsteady on his feet and has had some falls. Staff have consulted with his GP and the community nurse and are hoping to get a referral for him to attend a falls clinic. Records are kept of medical appointments and these show that service users have checks from the optician, dentist and when needed the chiropodist. Therefore service users health care needs are being met. At the time of the last inspection healthcare information was confusing and needed to be in sorted out so that all relevant information was in the appropriate place, not duplicated and easily accessible. This has been done and up-to-date information is available that clearly shows service users needs’ and how they have been met. None of the service users are able to self medicate and medication is administered by staff that have been trained and deemed capable to do this. This is usually a senior or a shift leader. Copies of staff medication assessments were available on file. Medication is stored in an appropriate lockable cabinet in the main office. Avenues Trust have developed a new medication policy in consultation with one of the Commissions’ specialist pharmacist inspectors and a copy of this was available in the home. Examination of the MAR (medication administration record) found that these had been appropriately completed and that the medication file contained photographs of each individual and a description of how their medication needed to be administered. Any handwritten amendments or additions to Medication Administration Records (MAR) sheets had been signed and dated by the person making the entry as required by the previous inspection. Guidelines were in place for PRN (when required) medication so that staff are clear as to when and how to administer this medication. Service users medication is appropriately stored and administered. Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 16 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 judgment has been made using available evidence including a visit to the service. There is a complaints procedure, available in a user-friendly format that would be followed in the event of any complaints being made. All staff have received adult protection training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. This gives service users a greater protection from abuse. EVIDENCE: Service users are not able to realistically make a complaint due to their profound learning and communication difficulties. The organisation has an appropriate complaints procedure and is available in a user-friendly format. This is included in the service user guide. Service users have access to independent advocates who can raise any concerns or issues on their behalf. Staff are aware of what to do and how to facilitate a complaint. Staff have received protection of vulnerable adults training. They are aware of what constitutes possible abuse and of the action that needs to be taken. This offers more protection to service users who are unlikely to be able to indicate that they have not been treated appropriately and are relying on other people to keep them safe. Since the last inspection members of the staff team reported an incident in which a service user was not treated appropriately and this was investigated under the adult protection procedures. Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 17 A random selection of service users’ finances was checked and cash amounts held agreed with records. Receipts were on file. Service users monies are securely stored and checks are made at each handover. At the time of the last inspection it was discovered that service users were routinely paying for staff meals and other staff expenses. This was not acceptable and has been stopped, as service users do not have the capacity to make informed decisions about how their money is spent. There is a service budget to pay for staff expenses. In addition service users have been compensated for any expenditure on staff expenses. One of the service users was also reimbursed for some items of furniture that he had purchased but which should have been purchased by the organisation. Systems are now in place to ensure that service users finances are safeguarded and appropriately used. Repton Drive DS0000060783.V325786.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, 25, 26, 27, 28, 29 & 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The service users live in a purpose built home that is suitable for their needs. Ongoing improvements are making it more homely and have given service users a choice of communal spaces. EVIDENCE: The home is purpose built, and was opened in late December 2004. The communal space consists of a large kitchen/diner, small lounge, laundry room and a garden. A conservatory has been added to increase the communal area. The building is accessible for wheelchair users throughout. Since the last inspection the kitchen, hall, lounge and laundry have been decorated. Staff and service users have been involved in the decorating. Each service user has a single bedroom that is suitable for his or her needs. All of these have an ensuite toilet, shower and washbasin. Two have overhead tracking for specialist hoists. Bedrooms are personalised according to individuals likes and Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 19 one service user’s room has been fitted with sensory equipment. The manager said that the bedrooms would be decorated after Christmas. There is a separate bathroom, with an assisted bath, and a separate toilet and shower and these are suitable for the service users needs. At the time of the last visit the garden area had not been developed and was not really usable. It was also prone to flooding. Major work has been carried out to address the problem. The family of a service user that lived in the home before her death wish to landscape the garden in memory of their daughter and weather permitting this work will now be able to be carried out in the new year. Therefore the service users should soon have a nice accessible garden to use. Repton Drive DS0000060783.V325786.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): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Staff are receiving the necessary training to give them the skills to meet service users’ current needs and provide an appropriate service for them. Staffing levels are sufficient to allow for this. Staff are properly recruited and the necessary checks carried out. This helps to protect service users and keep them safe. In addition to informal support staff receive formal supervision and regular staff meetings are held. This gives a chance for work practice and the development of the service to the discussed. EVIDENCE: There are 4 staff vacancies at the home. The manager said that interviews have been held and one person is due to start work on 8th January. They were waiting for the necessary checks to be carried out on other people. In the interim the vacancies continue to be covered by two regular agency workers Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 21 who are now very familiar with the running of the home and know the service users. In addition permanent staff work additional shifts. Therefore the service users are receiving a service from a consistent group of staff. During the visit staff were observed to spend time with service users, talking to them and giving them the support that they needed. There are usually three staff on duty during the daytime shift and two staff during the night. Staff spoken to said that they felt that the staffing levels were sufficient to meet the needs of the service users. The staff team all have experience of working with people with learning disabilities. Staff on duty said that they had received training since they started work in the home. This has included induction, adult protection, manual handling, food hygiene and understanding challenging behaviour. They also said that the training programme for the coming year was available and that they have been booked on other courses. A staff training record was available and this showed courses completed and those that staff were booked to attend in the coming months. Staff have a personal development plan. Staff were clear about their duties and responsibilities towards the service users. Therefore the staff team are receiving ongoing training to enable them to meet service users needs appropriately as required by the previous inspection. The organisation operates an appropriate recruitment procedure. Jobs are advertised, application forms completed and interviews held. The necessary checks are undertaken prior to staff commencing employment. Staff records are held centrally at the organisations head office in line with an agreement made with the Commission. Staff are receiving more regular supervision and staff meetings are being held each month. This gives staff the opportunity both collectively and individually to discuss work practice, any concerns and the development of the service. Feedback from staff was that “things are very improved at the home, staff are more involved and team work is good”. They felt that as a result of this the service users were more relaxed and happier. Repton Drive DS0000060783.V325786.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, 38, 39, & 42 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home is well managed and provides a safe environment for the service users. The registered provider monitors the service appropriately to check the quality of the service provided to service users. EVIDENCE: A new manager has been in post since the last inspection and she has started the process to be registered by the Commission. The manager has experience of working with people with learning disabilities and has completed NVQ 3. She will be undertaking the Registered Managers Award. Since the manager has been in post the requirements from the last inspection have been addressed. Staff feedback that the service is improving and that they are involved in developing the service. Staff also said that they feel very well Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 23 supported by the manager. Therefore the service users are benefiting from a well run home. The manager receives regular supervision and said that her line manager was very supportive and “pops in” every week. In addition the staff team said that they also felt they received more support from the organisation and that good work was now acknowledged. A representative of the organisation carries out monthly unannounced monitoring visits to the home and a report on this visit is left at the home and a copy of this sent to the Commission. The reports cover the necessary areas and indicate any action that is needed. There was also evidence that feedback on the service had been sought from relatives. Therefore the quality of the service provided to the service users is monitored by the organisation. The necessary health and safety checks are carried out and a safe environment is provided for the service users. The organisations procedure is that fire drills are carried out monthly and this happens. The last inspection recommended that the fire drill record sheet includes information about the time of the fire drill and who was present and this information has been included. This information can then be used to check that fire drills are being carried out at different times of the day and night and also that all staff and service users have taken part in fire drills over a period of time. There is a fire procedure and the action that should be taken in the event of a fire during the night has now been included. Hot water temperatures are now tested each week to ensure that they do not exceed the specified 43°C. The prescribed maximum temperature for the hot water & brief guidelines on what staff should do if the temperature is above 43° C. is now on the record sheet. This ensures that staff are clear about this and will further lessen the risk of scalding to service users. This was a recommendation from the previous visit. Repton Drive DS0000060783.V325786.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 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 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 3 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 3 3 X X 3 X Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 Timescale for action Daily recordings need to be more 31/03/07 specific and detailed and linked to individual plans. (Previous timescale of 31/08/06 not met). Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Repton Drive DS0000060783.V325786.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Repton Drive DS0000060783.V325786.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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