Inspection on 02/08/07 for Rushall Road (6)

This inspection was carried out on 2nd August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rushall Road (6) 11/07/06

Rushall Road (6) 01/03/06

Rushall Road (6) 20/09/05

Rushall Road (6) 17/03/05

Rushall Road (6) 14/10/04

Rushall Road (6) 23/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Rushall Road (6) 6 Rushall Road North Newnton Pewsey Wiltshire SN9 6TY Lead Inspector Elaine Barber Unannounced Inspection 8 August and 5 September 2007 2:00 th th DS0000028106.V336499.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 DS0000028106.V336499.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. DS0000028106.V336499.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rushall Road (6) Address 6 Rushall Road North Newnton Pewsey Wiltshire SN9 6TY 01980 630478 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) Steven@StevenAbbott.wanadoo.co.uk Mrs Jane Abbott Mr Steven Abbott Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000028106.V336499.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2006 Brief Description of the Service: Valued Lives is a private organisation, which operates five care homes for adults with a learning disability. All are small establishments, intended to offer a normal domestic lifestyle. The main lead for the organisation is taken by one of the registered persons, Mrs Jane Abbott. She is supported by other senior colleagues, including family members. Each of the Valued Lives homes is situated in Pewsey, or nearby small villages. Pewsey itself offers a range of amenities. The market towns of Marlborough or Devizes are within 15 minutes’ drive. Or, slightly further afield, there are the larger centres of Salisbury and Swindon. The organisation has a number of vehicles used to transport service users, who contribute towards the costs of these. Most service users now cared for by the organisation have been with them for a number of years. Time may have been spent in more than one of the homes that Valued Lives operates. Valued Lives also operates the Activity, Opportunity & Development centre (AOD). This is a day care facility which most of the organisation’s service users access, for at least part of each week. They pay a small weekly sum towards this. The unit is attached to the home in Ball Road, Pewsey but a new building is being converted for the service. 6 Rushall Road, in North Newnton, cares for up to three people. The present occupants are all male. All have single rooms, on the first floor. There is also a bathroom. There is a shared sitting room, dining room and kitchen downstairs. There is an enclosed garden area at the back of the house. The fees range from £623 to £790. DS0000028106.V336499.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included one unannounced visit to the home on 2nd August 2007. The people who lived in the home were on holiday at this time so a planned visit was made on 2nd September 2007 to meet with them. During the visits information was gathered using: • • • Observation Discussion with the manager and the manager of another service. Reading records. Other information and feedback about the home has been received and taken into account as part of this inspection: • The manager provided information prior to the inspection about the running of the home. The judgements contained in this report have been made from all this evidence gathered during the inspection, including the visits. What the service does well: There was a combined statement of purpose and service user guide with pictures. This provided information about the service so that people, or their representatives, could make a decision about whether the service would meet their needs. Each person had their needs assessed over a period of years to ensure that their needs would be met. They also had a contract with social services and the home which contained their terms and conditions and the fees. People had their abilities, needs and goals reflected in their individual plans to ensure that their needs would be met. They were supported to make choices and decisions in their daily lives. Risks in daily living were assessed and action was taken to reduce risks and promote independence. People were supported to take risks and access opportunities. People were provided with a range of activities and opportunities to take part in their local community. They were able to maintain and develop appropriate relationships with family and friends. People’s individual lives had an appropriate balance between necessary routines, and individual choice. Staff supported people to make choices including the colours of their bedrooms, activities and menu planning. Staff used recipe cards from Waitrose to help people to choose meals for the menu. People were offered healthy, nutritious and enjoyable meals. DS0000028106.V336499.R01.S.doc Version 5.2 Page 6 Each person’s choice of daily routine and the way they liked to be supported was recorded in their care plan. This ensured that people received personal support in ways that they preferred and needed. People had access to healthcare and had appointments with a range of health professionals. Their physical and emotional health needs were being met. The arrangements for managing and recording medication ensured people were protected. There was an appropriate complaints procedure. There had been no complaints since the last inspection. There was a policy about prevention of abuse. Staff had received training about abuse awareness and physical intervention. People were safeguarded by the home’s policies and procedures for complaints and protection. People lived in a comfortable and clean environment suited to their needs. Most areas of the home were well decorated and furnished. The décor and furnishings were comfortable and homely. The home was cleaned to a high standard. A range of training was provided for staff who kept their training up to date. All three staff who worked in the home had a National Vocational Qualification. People were supported by an effective staff team, who were appropriately trained, competent and qualified to meet their needs. There was a recruitment procedure and the standard about recruitment was met at previous inspections. People were protected by the home’s recruitment practices. The owner and manager were appropriately qualified and experienced to run the home. They was supported by other senior managers in the organisation so that people were generally benefiting from a well run home. There was a range of health and safety measures to ensure that the environment was safe for the people who lived there and the staff. People’s health, safety and welfare were promoted and protected. What has improved since the last inspection? A new care planning format was being introduced which was easier to read than the old format. New care plans were being developed for everybody. These focused on choice and independence. A new carpet had been laid in the hall, stairs, landing and living room since the last inspection. The lounge had been redecorated and there were new sofas. One of the bedrooms had been redecorated. A cleaning company had been employed to clean the home. These changes made the environment cleaner and more homely for the people who lived there. Refresher training for staff was held in November 2006 for health and safety, first aid and administration of medicines by special methods. This would DS0000028106.V336499.R01.S.doc Version 5.2 Page 7 ensure that people were cared for by staff whose training and practice was up to date. 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. DS0000028106.V336499.R01.S.doc Version 5.2 Page 8 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 DS0000028106.V336499.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the information they need to make an informed decision about whether the service can meet their needs. People’s needs are assessed so that these needs can be met. Each person has a contract and statement of terms and conditions. EVIDENCE: There was a combined statement of purpose and service user guide with pictures. This provided information about the service. There have been no recent admissions to the home. All the people who live at Rushall Road have lived within Valued Lives for a number of years. They have therefore established their routines. There has also been continuity and stability in the staff team. Many have several years’ experience. This has given them a depth of knowledge about the people who live in the home. Each person has had their needs assessed over a period of years. DS0000028106.V336499.R01.S.doc Version 5.2 Page 10 Each person had a contract with social services and the home. These contained their terms and conditions and the fees as well as the contribution paid by social services and the person. DS0000028106.V336499.R01.S.doc Version 5.2 Page 11 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. People had their abilities, needs and goals reflected in their individual plans. They were supported to make choices and decisions in their daily lives. People were also supported to take risks and access opportunities. EVIDENCE: A recommendation was made at the last inspection that work should continue to develop the content and presentation of care plans and associated information. A new care planning format was being introduced which was easier to read than the old format. New care plans were being developed for everybody. Each person also had an old style care plan. The date when the new plans were started was recorded. There were also spaces for the person, their key worker, their care manager and the home’s manager to sign to show who was involved in developing the plan. Care plans were reviewed approximately every six months. DS0000028106.V336499.R01.S.doc Version 5.2 Page 12 The new plans focused on developing choice and independence. There were examples of choice and decision making in the care plans and ways in which people were supported to make choices. Examples of when people made choices and decisions were also recorded in the daily records. Two staff members described how people made choices of colours for rooms and carpets. The records showed that there was a choice of activities. Each person had risk assessments for all aspects of daily living. The assessments focused on promoting independence and included the action to be taken to reduce risks. DS0000028106.V336499.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were provided with a range of activities and opportunities to be involved in their local community. People were able to maintain and develop appropriate relationships with family and friends. There was an appropriate balance in people’s daily lives between necessary routines and individual choice. People were offered healthy, nutritious and enjoyable meals to meet their individual needs and preferences. EVIDENCE: People had opportunities to express their spiritual needs. There was a special service at the local church for people from Valued Lives about every three weeks. Other people from the community joined them in this service. There was information about these services in the parish magazine. Two of the DS0000028106.V336499.R01.S.doc Version 5.2 Page 14 people had recently been confirmed into the church. People from the church also visited the day service to give communion. People attended the Valued Lives day service where they had a wide range of activities. The records showed that activities included arts and crafts, walks, shopping trips and visits to the library. On the first day of the inspection the people were away on holiday in a caravan at Highcliffe. Arrangements for contact with families and friends were recorded in the care plans and personal records. The service manager said that relatives visit the home and phone people. She also said that staff support people to visit their relatives and have outings with relatives. People had friends from some of the other houses in the organisation whom they saw regularly. They had opportunities to meet new people at the day service as people from the community were starting to attend. They also met friends at a social club, which they visited once a fortnight. The manager reported that people were involved in the routines of the home including shopping, meal preparation, washing and cleaning. The daily records confirmed this. During the second day of inspection people were being supported to sort their washing and put items into the tumble drier. They were also observed choosing to spend time in the lounge together, watching television, after coming home from their day service. The service manager reported that they used recipe cards from Waitrose to help people to choose meals for the menu. All three people had been tested for food intolerances and the meals took account of these. A dietician had advised about the diet provided. Herbal teas and fruit juices were offered. High quality ingredients were provided. The menu showed that a balanced diet was offered with a wide range of choice. DS0000028106.V336499.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. People received personal support in ways that they preferred and needed. Their physical and emotional health needs were being met. The arrangements for managing and recording medication ensured people were protected. EVIDENCE: Each person’s choice of daily routine was recorded in their care plan and personal records. The ways in which they liked to be supported were recorded in detail. Details about health care needs were also recorded in the personal notes. The daily records showed that people had appointments with health care professionals. Dates of appointments and the outcome of the visit were recorded. People had access to the GP, district nurse, continence advisor, podiatrist, optician and dentist. An occupational therapist had given advice on suitable equipment and techniques to reduce the risk to people with decreased mobility when using the landing and stairs. One person had recently received an appointment to see a physiotherapist. DS0000028106.V336499.R01.S.doc Version 5.2 Page 16 There was a policy about medication. Each person’s personal notes contained a record of the medicines they took. There was also a description of how people consented to take their medication. Medication was reviewed by the GP. Each person had a list of homely remedies, which was agreed by the GP and there was guidance about medication to be taken ‘as required’. Appropriate records were kept when medication was administered and there was a booking in and out book for medication received into the home and returned to the pharmacist. All staff had training about medication, including special methods of administration and this was reviewed annually. Medication was stored in a locked cupboard. However, it was in a position where the medication could be affected by heat and steam. There is a risk that some medicines can be affected by changes in temperature so the internal temperature of the cupboard should be monitored. DS0000028106.V336499.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. People were safeguarded by the home’s policies and procedures for complaints and protection. People were protected from abuse, neglect and self harm. EVIDENCE: There was an appropriate complaints procedure. There had been no complaints since the last inspection. There was a policy about prevention of abuse. There was information about the Department of Health ‘No secrets’ guidance. Each member of staff had a copy of a leaflet about the local multi-agency adult protection procedures. All members of staff had been on a course about abuse awareness in November 2006. Staff also had training about physical intervention accredited by the British Institute of Learning Disabilities. There was also video training and guidelines about dealing with allegations of abuse. The service manager said that there had been no allegations of abuse. The staff managed people’s personal money and appropriate records were kept of all transactions. DS0000028106.V336499.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. People lived in a comfortable and clean environment suited to their needs. EVIDENCE: 6 Rushall Road, North Newnton is situated in a row of houses on a main road through the Vale of Pewsey. There are views of the surrounding countryside. Amenities in the immediate local area are limited. The nearest large centre is the village of Pewsey approximately three miles away. The home was generally in a good state of decoration and repair. A new carpet had been laid in the dining room the previous year. A new carpet had also been laid in the hall, stairs, landing and living room since the last inspection. The living room had also been redecorated and there were new sofas. DS0000028106.V336499.R01.S.doc Version 5.2 Page 19 A recommendation had been made at the last inspection that the radiator covers should be repainted to make them look more homely; the bedroom with the peeling wallpaper should be redecorated and the kitchen cupboards should be repaired and repainted or replaced. The bedroom identified had been redecorated but the radiator covers had not been painted. The service manager said that the owners were negotiating with the landlord to replace the kitchen cupboards. There were infection control guidelines. Recently a cleaning company had started to clean the house and they came once a week. The home was cleaned to a high standard. There was a washing machine in the kitchen and a tumble drier in the garage. The registered manager reported that people bring their own washing downstairs and do their washing with varying degrees of help from staff. During the inspection one person was seen putting their washing into the tumble drier and taking it out when it was dry while another put their washing away. DS0000028106.V336499.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, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported by an effective staff team, who were appropriately trained, competent and qualified to meet their needs. People were protected by the home’s recruitment practices. EVIDENCE: Each home within Valued Lives had some staff specifically allocated to it. Cover was then made up by other staff, who worked in more than one setting. The owner’s aim was to employ sufficient people so that, even if they were one staff member down, there were still enough to cover all the organisation’s services without needing to rely on external agencies. Rushall Road had three staff mainly allocated to it. The home aimed to keep continuity of staff, to minimise any disruption that might unsettle people who lived in the home. There were two regular staff and one person covered holidays and sickness. The rota showed that there was always one person on duty. At nights, one person slept in. An on-call manager was available if DS0000028106.V336499.R01.S.doc Version 5.2 Page 21 required. All the staff had worked in the home for several years and were familiar with people’s needs. The standard about recruitment was met at a previous inspection and no new staff have been recruited since. All of the three staff who worked in the home had a National Vocational Qualification (NVQ). One had NVQ level 2, one had NVQ Level 3 and one had NVQ level 4. This exceeds the standard of 50 of staff having an NVQ. Staff had a range of training including health and safety, food hygiene, first aid, medication, including special methods of administration, and abuse awareness. Refresher training was held in November 2006 for health and safety, first aid and administration of medicines by special methods. Food hygiene training was planned for September 2007. DS0000028106.V336499.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 was generally good although further work was needed on quality assurance. This judgement has been made using available evidence including a visit to this service. The registered manager was suitably qualified, competent and experienced and on the whole people benefited from a well run home. The home was not providing evidence that they took responsibility for their own quality assurance and that people’s views underpinned all self-monitoring, review and development by the home. People’s health and safety were protected by the systems in place. DS0000028106.V336499.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered person for Valued Lives is Mrs Jane Abbott. She has lengthy experience of working with people with learning disability, and has owned and operated her own services for many years. She is supported by other senior staff within the organisation. Together, they oversee all five services currently run by Valued Lives. The registered manager, Steve Abbott, has a National Vocational Qualification in management at Level 4. For the last two inspections the registered manager had been working on their quality assurance for the service. The quality assurance framework was based on the systems in the house including policies and procedures, care plans, records and staffing. A consultant had provided advice and guidance about quality assurance. The views of people who used the service, relatives and visiting professionals had been collected. These had been collated into a quality assurance report for the whole service covering five homes. There was also a draft review report of the previous three years. Areas for improvement were identified. At the last inspection the owner reported that they needed to complete the summary of what had taken place over the last three years and type up the goals for the next three years. It was also identified that a copy of this report needed to be finalised, sent to the Commission and made available to all people who used the service. A requirement was made and this had not been addressed. The annual quality assurance process was due to be started again by collecting the views of people who lived in the home. The service manager reported that there were no plans to do this. There was a health and safety policy to comply with the relevant regulations. A number of general risk assessments and safe working procedures had been recorded. There were also individual risk assessments. There were arrangements for the training of staff in moving and handling, fire safety, first aid and food hygiene. A monthly ‘hazard’ inspection of the home was carried out. Hot water temperature regulators were fitted to the taps. There were COSHH assessments, equipment was regularly serviced and portable appliances were tested annually. There was a fire risk assessment and there were records of fire safety checks. The fire officer visited in September 2004 and was satisfied with the risk assessment. He advised that the fire risk assessment should be amended if there were any changes to the fire safety measures. Staff reported that there had been none. The radiators upstairs were covered. Those in the living room and dining room were not. The member of staff reported that this was because the risks were lower downstairs as people were always observed by staff when they were in the living room and dining room. Information was available about what to do in the event of a heat wave. DS0000028106.V336499.R01.S.doc Version 5.2 Page 24 DS0000028106.V336499.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X DS0000028106.V336499.R01.S.doc Version 5.2 Page 26 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 YA39 Regulation 24 Requirement The registered person must supply to the Commission a copy of the report about the quality assurance survey and make a copy of the report available to service users. Timescale of 30/09/06 has not been met. The registered person must continue to implement an effective cycle of quality assurance and ensure that the views of all stakeholders are represented. Timescale for action 30/12/07 2. YA39 24 28/02/08 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 YA20 YA24 Good Practice Recommendations The temperature of the medication cupboard should be monitored to ensure it does not exceed the limits identified in the patient information leaflets. The radiator covers should be repainted to make them look more homely. The kitchen cupboards should be repaired and repainted or DS0000028106.V336499.R01.S.doc Version 5.2 Page 27 replaced. DS0000028106.V336499.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Foor Colston 33 33 Colston Avenue BS1 4UA 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 DS0000028106.V336499.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!