Inspection on 22/02/07 for Rydal House

This inspection was carried out on 22nd February 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

Rydal House 17/02/06

Rydal House 15/09/05

Rydal House 24/03/05

Rydal House 02/11/04

Rydal House 15/12/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Rydal House 6 Spratslade Drive Dresden Stoke-on-Trent Staffordshire ST3 4DZ Lead Inspector Mrs Mandy Brassington Key Unannounced Inspection 22 February 2007 10:00 Rydal House DS0000029772.V331450.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 Rydal House DS0000029772.V331450.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. Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rydal House Address 6 Spratslade Drive Dresden Stoke-on-Trent Staffordshire ST3 4DZ 01782 330854 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) Mr Alan John Bradshaw Mrs Joy Bradshaw Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17 February 2006 Brief Description of the Service: Rydal House is a registered care home for up to eight adults with learning disabilities of both genders. It is one of three homes owned by Mr and Mrs Bradshaw. The home is located in Stoke On Trent, Staffordshire and is accessible via public transport and is in close proximity to local amenities. The property consists of a large mature semi-detached house. The exterior of the property is in keeping with the local community. The home provides eight single occupancy bedrooms, of which are located over the three floors. There is no passenger lift or specialist aids or adaptations available and these are not currently required for the service users living in the home. Five bedrooms are equipped with an en suite and three bedrooms on the ground floor have a washbasin. One toilet with bathing facilities is located on the ground floor and there is a shower room on the first floor. The property also provides a large lounge with dinning facilities, a kitchen and laundry facilities in the basement. Service users have access to an enclosed garden located at the rear of the property. Parking is available on the road. Staffing is provided on a twenty-four basis. The home provides support on a twenty-four basis to support individuals to live a socially inclusive lifestyle and develop necessary skills for independent living. Following assessment of risk, individuals are able to access community services and facilities independently and take the lead role in their care. The registered provider informed the Commission for Social Care Inspection on 22 February 2007 that the fee level for the home is between £325 and £326 per week. Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered all of the core standards. The inspection took place over 7 hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. A tour of the home was undertaken. On the day of the inspection, the home was accommodating eight people. Prior to the inspection visit, survey information has been requested from individuals and their relatives. A Random Inspection was conducted on 10 July 2006 and addressed previous requirements and included an inspection of Activities, the Environment, and Health and Safety. Some details of this inspection are included in this report. The inspection included an examination of records, indirect observation, discussions with five service users, the manager, the senior care staff on duty. Case tracking of four care plans was undertaken. Two staff records were examined and observation of daily events took place. The Medication storage system and medication procedures were inspected. Four requirements and four recommendations were made as a result of this visit. What the service does well: The home provides individuals with daily opportunities to be involved with activities in the home and within the community. Service users attend a variety of work, education placements and leisure activities of their choosing. Daily activities are flexible and individuals are able to choose how to spend their time. Individuals have opportunities to develop relationships with people in the home and the community and to make and sustain friendships. Personal relationships are recognised and supported. The staff at the home have a friendly and professional approach, and privacy and dignity are upheld within the home. Staff offer choices and enable the service users to make decisions in their daily lives and demonstrate a good knowledge of up to date practices, and of individuals needs and how to support people. Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 6 Service users and staff members have developed good relationships and individuals are confident to express their views. Service users comments regarding staff included: ‘The staff listen to you.’ ‘Staff help you if you have any problems.’ ‘You can have a laugh with the staff.’ The registered providers take an active role in the overall wider management of the home and have developed good relationships with all individuals. The providers have demonstrated a commitment to continually develop the service and give support to the manager and staff. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rydal House DS0000029772.V331450.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 Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals have access to a range of information regarding the home prior to admission. Prospective individuals are given the opportunity to spend time in the home prior to deciding to move in. EVIDENCE: There has been one new referral since the last inspection. Examination of the care records revealed that the registered person had conducted an assessment and confirmed in writing that the home was suitable to meet the needs of the individual. A care management assessment had been conducted. The service user had confirmed in writing that they had received a copy of the Service user Guide and terms and conditions of occupancy. During the visit the service user stated that they had been able to spend time at the home prior to deciding to move there. Discussion with other service Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 9 users revealed the individual already knew a number of people from joint activities at local college. Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals are supported to make decisions and take an active role in all aspects of their daily life. Care plans need to be reviewed to reflect the person centred approach within the home. EVIDENCE: A sample of four plans of care were inspected. Each plan contained personal details, an assessment and details of individuals needs and the support required along with identified risks. The new manager is currently reviewing the plans of care. A number of the plans have a detailed task analysis, though these are the same for each individual and therefore did not record the individual support required and recognise each person’s abilities. Risk assessments for some of these activities identified the different risks associated with a task or activity and how staff were to provide support. The manager is currently in the Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 11 process of reviewing all plans of care and using a different format. These were discussed with the manager to ensure that plans of care are person centred and are linked to the overall assessment of needs. Plans of care included a twenty-four hour profile, which recorded brief information on daily activities and support. The profile was written by staff in the third person. This was discussed with the manager and recommended to review the profile and to support individuals to be involved and to write this. The home recognises the right of individuals to take control of their lives and to make their own decisions and choices. Individuals are consulted regarding all activities during the day and supported to take the lead role. On the day of the inspection, individuals were talking about having a new pet and the benefits and possible problems of having different sorts of animals. Service users were confident in the discussion and able to express opinions freely. Individuals reported that they were able to make decisions about their life for areas such as, choosing meals, activities, liaisons with family and personal finances, and are supported encouraged to take responsible risks. Staff members confirmed this. Service users meetings take place bi-monthly, or more frequently if required. A record of minutes is recorded. Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are involved in meaningful daytime activities according to choice, individual interests and capability. Education and occupation opportunities are encouraged, supported and promoted. EVIDENCE: On the day of the inspection, five service users were completing work placements and college courses. Three service users were in the home and a trip had been organised to Henley for lunch and shopping. Discussion with service users and staff revealed that there is a range of day opportunities attended including work placements at Bridle gate and Oak tree Farm, and attendance at local colleges, completing a variety of courses for Art and Craft, Literacy, computer skills and Independent Living. Service users Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 13 confirmed they were able to choose work and learning activities. This financial year individuals have only been able to access to a reduced number of college placements due to a change in eligibility criteria. The staff at the home have explored local community options and individuals reported that individuals also attend a local Keep Fit group and Drama Class. During the day, discussion took place three individuals at length regarding the home, the support received from staff, daily events and social inclusion. Later in the afternoon all service users returned home and it was pleasing to see the interaction between individuals and the members of staff was relaxed and comfortable, individuals were able to express opinions and there was friendly banter. Service users were enthusiastic to discuss the day’s events and one individual brought home a hand-crafted bowl, which was very decorative. One service user stated he had been digging and working in the gardens. Individuals stated they were able to access local facilities with support and knew how to travel to local places. Service users are able to access the community without staff support following assessment of risk. Two service users reported that they often prefer to go out in small groups rather than individually. Inspection of records and discussion with staff and service users revealed that individuals chose to be involved in a variety of social activities, including going to local pubs, social clubs, bowling, the cinema and meals out. Individuals had visited the Regent Theatre and watched a performance. One individual had enjoyed a surprise birthday party organised by family members for all his friends and family. The individual and other service users spoke very favourably of the event and were pleased they had been able to keep the party a surprise and all individuals said they had a good night and enjoyed dancing. Individuals confirmed they are able to participate in the food shopping for the home. Service users are able to choose each meal, though often as a group decide on one or two meals. Individuals are able to prepare and cook the meals and one service user reported that there is a flexible roster to help tidy away after each meal. Meal times are flexible dependant upon the activities taking place. Upon arrival at the home individuals were eating breakfast and reported that they are able to get up later when they do not have any commitments. Rydal House DS0000029772.V331450.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 judgement has been made using available evidence including a visit to this service. Personal support is responsive to individual’s needs and preferences. The delivery of personal care is flexible and person centred and staff respect individual’s privacy and dignity. EVIDENCE: Plans of care recorded the level of support each individual required; many individuals require prompts to complete personal care to ensure daily tasks are carried out. A review of the plans of care is detailed in the outcome area for Individual needs and choices. The plans of care, recorded individual’s health needs, details of appointments and outcomes. All service users are registered with a General Practitioner (GP). Discussion with one service user revealed in general, they are supported to visit the Doctor with a member of staff but can see the GP in private. Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 15 The home uses the Monitored Dosage System (MDS) and medication is dispensed by a pharmacy into weekly cassettes. Inspection of Medication and Medication Administration Records (MAR) were satisfactory. One service user is responsible for administering their medication. A plan of care and assessment of competency is carried out prior to individuals self-medicating. The person administering the week’s supply of medication to the service user records this on the Medication Administration Record Sheet. Discussion with the manager revealed she is responsible for auditing the medication system including the records. It is recommended that this audit be documented, as it is evidence of an excellent practice and reviewing of the service provided. Each service user had a Homely remedies sheet signed by the G.P. recording what may be administered. The manager reported that staff had received training to safely administer and that only staff that had received the training were responsible for medication administration. There is a record of staff signatures and initials to easily identify who has administered medication. Rydal House DS0000029772.V331450.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 judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. A record of all individuals monies are maintained, though this needs to be reviewed to ensure it is robust. EVIDENCE: Service users reported that they keep a small amount of personal money and other monies and valuables are kept securely in the home. Individuals have a personal bank account. Three personal accounts were inspected and one account had a discrepancy. Inspection of the records revealed that most of the entries were only signed by one member of staff and service users had not countersigned the records. Many transactions were for shared activities with other service users, but there was not a suitable auditing system in place. This was discussed with the manager who agreed a more robust procedure needed to be implemented. Service users were aware of how to make a complaint and had a copy of the procedure. All service users spoken with reported that if they had any concerns the manager would address these promptly. Staff have access to the Vulnerable Adults Procedure and Whistle Blowing Procedure and are currently receiving training. Discussion with one member of Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 17 staff demonstrated a good knowledge of the procedure and how to deal with any disclosure. Rydal House DS0000029772.V331450.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, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home meets the needs of the individuals and can be changed if their needs change. Service users are encouraged to personalise their bedrooms to reflect their interests. EVIDENCE: The home is a mature semi-detached property in a residential area of Stoke. It is situated near the end of a cul-de sac. The home is furnished to a good standard and has kept many of the original features to create a homely environment. Accommodation is provided over three floors for up to eight people. On the ground floor, there is a large lounge with dinning facilities and a kitchen. There is one en-suite bedroom and three single bedrooms and a separate bathroom. On the first floor, there are three en-suite single bedrooms and one Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 19 en-suite single room on the second floor. The laundry facilities are situated in the basement. There is a secure garden to the rear with grasses area mature plants and a patio section with barbeque facilities. All bedrooms have been decorated to reflect individual interests and contain a wide variety of personal and electrical items. Three individuals reported that they are responsible for their rooms in terms of ensuring it remains clean and tidy; staff are available to support individuals. Staff are responsible for all domestic duties in the home and reported that where possible service users are encouraged to participate. All areas of the home were clean and well presented. A risk assessment has been completed on one first floor bedroom in relation to the fire exit. The provider reported that this is to be fitted with an alarm to notify staff if the door has been opened. Hot water pipes around the home need to be covered. Rydal House DS0000029772.V331450.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, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing provided is based around delivering outcomes for the people using the service, with more staff being available at peak times of activity. Service users have confidence in the staff that care for them. EVIDENCE: The home’s shifts are flexible to suit the needs of the service users, though are generally across three day shifts. Generally, the shift pattern is: 1 1 1 1 1 member member member member member of of of of of staff staff staff staff staff works works works works works 8.00am – 5.00pm 5.00pm – 10.00pm 9.30am – 2.00pm 4.00pm – 8.00pm 10.00pm – 9.00pm The shift pattern is variable due to individuals usual routines, and education and work commitments. The manager reported that where specific activities Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 21 are organised additional staff may be on duty. Two service users stated that ‘there is always enough staff available if you want to do anything.’ The home has a good recruitment procedure that ensures that staff are suitable to work with vulnerable people. A sample of three staff files were examined and demonstrated that thorough pre employment checks are carried out. Criminal Records checks (CRB) had been undertaken in all instances, and there was proof of identity, two references and a completed application form on file. There has been one new member of staff since the previous inspection and the interview questions and responses had been recorded. Discussion with the manager revealed that the person had begun an induction to the home but this was not evidenced. It is recommended that all areas of the induction are documented and demonstrate this meets the Skills for Care Common Induction Standards. The new manager had begun staff supervision and had carried out an annual appraisal. The manager reported that the home is committed to developing the skills of the staff team and all staff are working towards or have an NVQ Qualification; two staff have an NVQ 2 Qualification and 3 staff are working towards gaining an Award. On a previous inspection, the Provider discussed a new training package that has been purchased to ensure all staff receive the required training. The manager has received training to support and assess the staff, and to ensure individuals have gained sufficient knowledge and are competent. An external verifier will audit completed training. This training package had started within the home with Protection of Vulnerable Adults. The manager reported that Food hygiene and Health and Safety are included. This will be inspected on the next visit. From discussion with staff and observation of practices, it was evident that staff are enthusiastic and committed to providing a good service and enabling individuals. Service users spoke positively about the staff team and from observation, relationships were relaxed and open. Service users and relatives comments regarding the staff included: ‘The staff listen to you.’ ‘Staff help you if you have any problems.’ ‘You can have a laugh with the staff.’ Rydal House DS0000029772.V331450.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 judgement has been made using available evidence including a visit to this service. The manager has a clear understanding of the key principles and focus of the service, and is working to improve services and provide an increased quality of life for service users with a strong focus on enabling. EVIDENCE: The manager has been in post for four weeks. Prior to this, there was a period of time that the new manager worked alongside the former manager to ensure a thorough handover. The manager has submitted an application to begin the Fit person process to become the registered manager. The manager reported that she has obtained an NVQ III qualification and is to enrol and complete the NVQ IV. Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 23 From discussion with the manager and observation of practices, it was evident that the manager has a good value base, knowledge and experience of working with adults with a learning disability. The manager is working with the staff team and reviewing their role to ensure that staff are proactive and view their role as an enabler rather than supporting individuals. The health, safety and welfare of staff and service users were protected. The registered person had ensured that all maintenance work, repairs, annual checks, testing of equipment and regular fire drills are undertaken. Required checks have included: Annual Gas Safety Test was conducted in May2006. An Electrical Inspection of the Fire Alarm System was conducted in June 2006. Portable appliance tests were carried out in October 2006. Water temperatures are carried out monthly. An Asbestos plan has been completed. Suitable Fire equipment checks, evacuations and training had been carried out. The Fire officer had visited the home on 20 February 2007 and will prepare a report. Following the visit the manager had implemented a new policy for closing all magnetically held Fire doors at night. The home has environmental assessments of risk for each room and included, radiators, infection control, use of electrical equipment and moving provisions and goods. The registered person had completed a Fire Risk Assessment and has included the dependency levels and needs of service users. There is an Emergency Contingency Plan linked to the assessment. The home conducts Annual Satisfaction Surveys. Individuals are able to comment on a variety of issues including, the home in general, the environment, meals, staff attitudes and respect, access to health care, and holidays. The surveys were discussed with the manager in relation to suitability for individuals with a learning disability as the forms have five degrees of satisfaction rating. The current format requires support from a member of staff. It is recommended that these be reviewed to reflect the needs of the service users. Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 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 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3. 4 Standard YA6 YA23 YA24 YA24 Regulation 15 (1) 17 (2) 13 (4)(a)(c) 13 (4)(a)(c) Requirement To review plans of care in line with person centred principles To develop a robust system of recording individuals finances, as schedule 4 (9) To fit an alarm to the fire exit door in one bedroom as identified in the risk assessment Hot water pipes to be covered, This is outstanding from report 04/10/06. Timescale for action 22/05/07 30/03/07 30/03/07 22/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA6 YA20 YA34 YA39 Good Practice Recommendations Twenty four hour profiles to be written by service users with support from staff To record the auditing of the medication systems and records. To maintain a record of staff induction To review the format of the quality assurance reviews to a suitable format Rydal House DS0000029772.V331450.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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