Inspection on 13/01/06 for Sambourne Road (58)

This inspection was carried out on 13th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sambourne Road (58) 27/06/07

Sambourne Road (58) 17/08/05

Sambourne Road (58) 05/02/05

Sambourne Road (58) 06/09/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Sambourne Road (58) 58 Sambourne Road Warminster Wiltshire BA12 8LE Lead Inspector Tim Goadby Unannounced Inspection 13th January 2006 09:55 – Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 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 Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 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. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sambourne Road (58) Address 58 Sambourne Road Warminster Wiltshire BA12 8LE 01985 217147 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) H5044@mencap.org www.mencap.org.uk Royal Mencap Society Mr Byron Nadgie Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1), Physical disability (1) of places Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users who may be accommodated at any one time is 6 Only the one, named, female service user with a learning disability referred to in the application dated 9 March 2004 may be aged 65 years and over Not more than 1 male service user in the age range 18 - 64 years with a physical disability may be accommodated at any time 17th August 2005 Date of last inspection Brief Description of the Service: 58 Sambourne Road provides care and accommodation for up to six adults with a learning disability. The home is also registered to care for one person with physical disability. The service is operated by Mencap, a national voluntary organisation in the learning disability field. The property is a detached house in a residential area of Warminster. It is within walking distance of the towns amenities. There are also good public transport links. The building dates originally from Victorian times, and has been extended at one side. All service users have single bedrooms, one of which is downstairs. Each bedroom has a hand basin, but there are no other en-suite facilities. There is a shower on the ground floor, and a bathroom upstairs. There is also another separate toilet, off the half landing on the staircase. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in January 2006. A total of 5.5 hours was spent in the home. The following inspection methods have been used in the production of this report: indirect observation; pre-inspection questionnaire, completed by the provider; sampling of records, with case tracking; discussions with service users, staff and management; survey of service users, relatives and professionals; tour of the premises. What the service does well: What has improved since the last inspection? The involvement of service users in the planning of their own care has continued to develop. The implementation of ‘person centred planning’ is well underway. Service users are fully engaged in developing their own folders for this exercise. Staff are also receiving relevant training. The approach taken ensures that the support given is clearly linked to the goals and preferences of each individual. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 6 The home is now notifying all significant events to the CSCI without delay. This upholds the regulatory requirements, and means that service users can feel confident their protection is enhanced by the open and transparent sharing of key information. Improvements have been made to service user record keeping, in response to recommendations of the previous inspection. Firstly, if sensitive information is kept in a more confidential file, mentions of such issues in more generally available records are clearly cross referenced. This ensures that records can be used effectively to identify issues of importance for people. Secondly, staff do not make detailed entries about individual service users in general records, such as communication books. This helps to preserve the confidentiality of individual information. The home’s Statement of Purpose and Service User Guide, which are key documents setting out information about the home and its facilities and services, have been reviewed and completed. A version of the Guide has also been produced on DVD, with the full participation of the current service user group. This means that prospective service users have the necessary information to make decisions about a possible move to the home, based on feedback from the existing residents. 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. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 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 Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5 Prospective service users have the necessary information to make a choice about the home. Standards relating to admissions to the home were not applicable at this inspection. Service users have their needs and aspirations met by the home. Service users have individual terms and conditions of residence in the home. These have been produced in formats designed to be appropriate to them. EVIDENCE: The service has a Statement of Purpose, and Service User Guide. These have been updated since the previous inspection, and copies of the revised versions supplied to the CSCI. They now cover all of the required criteria for these documents. A version of the Guide has also been produced on DVD, with full participation of the current service user group. The home has an established group of five residents, with one service user vacancy at present. There were no prospective service users under active consideration at the time of this inspection, as the home’s vacant room needed attention before it became fit to occupy. As the current group consists of three Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 9 males and two females, service users have expressed a preference for another female, to even up the balance. Sambourne Road has a philosophy of ‘active support’. The approach taken promotes service users maintaining and developing skills, and accessing a range of opportunities. Input from staff is given in line with the needs and preferences of each individual. The service user group are able and independent in many areas, and this is encouraged and enhanced by the support they receive. Other relevant agencies are also involved in supporting particular needs which people may have. The local Community Team for People with Learning Disabilities (CTPLD) includes various professionals who can offer input. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 8 Service users contribute fully to devising their individual plans, which reflect their strengths, needs, preferences and goals. Service users can make choices and decisions in their daily lives, and about the conduct of the home. EVIDENCE: Sampled care plans are clear, comprehensive and up to date. Service users have significant input into the documents. Records are discussed with them, and they sign to indicate this. Most are written in the first person, based on the person’s own words. This process is developing, in line with the application of ‘person centred planning’. Service users have their own folders, filled with information about important aspects of their lives, and illustrated with relevant photos. It is clear that each person is fully involved and engaged in producing their plan, which is a meaningful way of getting them to identify their own goals. Further developments are proposed, including the use of audio and video versions of plans, to support the paper copies. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 11 Each service user has an allocated staff keyworker who works closely with them. They produce monthly reports on each person. These are summaries, compiled from other records, and from talking to the individual. These monthly updates provide good evidence of regular review. Fuller reviews are also held at suitable intervals. Other relevant people contribute to these, such as relatives, and any professionals involved with an individual’s care. For service users at Sambourne Road, decision making is an integral part of their lives. The approach underpinning all that the home does is to promote opportunities to exercise independence. This is set out in a mission statement called ‘Our House, Our Choices’, which stresses each service users’ right to make choices in all aspects of their daily lives. This is within a framework of taking a full part in all the necessary jobs in the household, and attending any other settings that form part of the weekly routine. If any limitations are put in place, the reasons for these are documented within individual care plans and risk assessments. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15 & 16 Service users have the opportunity to maintain and develop skills. Service users are provided with a range of activities and opportunities, offering them full engagement with their local community. Service users are able to maintain and develop appropriate relationships with family and friends. Service users’ rights and responsibilities are upheld, balanced with appropriate steps to safeguard their welfare. EVIDENCE: Service users are supported to develop their independence and to reach their maximum potential. The current group are able in many areas. Support from staff therefore often takes the form of advice and encouragement. People are enabled to have control in many aspects of their daily lives. For instance, using clear and detailed risk assessments to support individual Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 13 judgements, service users are able to be in the house without staff supervision for set periods of time. In connection with this, they have been able to demonstrate sets of key skills that uphold their safety. Each person contributes their fair share to the overall daily running of the home. Service users regularly answer the door to visitors, answer the phone, and make drinks for people. They are also allocated responsibility for the various household chores. People undertake a range of activities outside the home. These include some day service resources that are specifically for people with learning disability. Service users also attend sessions at local colleges, and some have either voluntary or paid employment. Service users can choose how to spend their leisure time at home. Each has their own bedroom. There is also a quiet room upstairs, which is used by people for hobbies such as sewing, and personal computing. People also regularly access amenities in the local community. They are enabled to do so independently, in line with risk assessments. Some can also travel further afield, making use of public transport. Service users also have the opportunity to go on holiday. Some of them make the necessary arrangements themselves, with staff support. The destinations and activities which people choose reflect their own interests and preferences. As well as holidays organised from within Sambourne Road’s current client group, some service users also go away with friends or family. People are able to maintain key relationships. All service users have some family contact. They are supported to visit their relatives. Over Christmas the home closed for a week as all the residents were away with their families. People also have some other significant friendships, such as former residents, colleagues from work or college, and members of churches they attend. This means that some individuals have very active social lives. Information about important relationships forms a key part of person centred plans. Service users’ own rooms are considered their private personal space. People have keys to their bedrooms, and lockable space within them. Staff will not enter without permission. Agreements are in place about emergency situations that might mean having to override this. Service users have unrestricted access to all communal areas, and keys for the front door, in line with risk assessments. Since the previous inspection, a number of additional hours of staff support per week has been provided for one service user. This is to help promote the Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 14 individual’s re-engagement with a more normal daily routine. As part of this, the person has begun to attend both work and college. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. The key standards in this section were met at the previous inspection. EVIDENCE: Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Service users are safeguarded by the home’s policies and procedures for complaints and protection. EVIDENCE: Mencap’s organisational complaints arrangements are appropriate. Information on how to raise concerns is readily available for service users, in various formats. This includes details on how to contact people outside the home, including the CSCI. Since the previous inspection there has been one formal complaint, relating to a former service user of the home. This was upheld in one aspect, but not upheld for the majority of the issues raised. The CSCI was notified of the complaint when it was received, and of the actions taken by Mencap in response. These are deemed to be appropriate. Policies are also in place regarding abuse, and the protection of vulnerable adults. These include information about the local multi-agency procedure within Wiltshire. All staff receive training on these topics as a key element of their induction, and have update sessions at least once every three years. There is also a policy on how staff can raise any concerns they may have about practice. The service is intending to work with its users to make a video about safety and protection issues. This will cover situations both at home and elsewhere. The plan is that it can then be shown to people at regular intervals, to reinforce the messages contained. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 17 Records are kept of any significant incidents which occur. In response to a requirement of the previous inspection, staff have been made aware of the need to report such events to the Commission. A copy of the relevant guidance for such notifications is available in the home. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28 & 30 Service users live in a comfortable, clean and safe environment, suitable to their needs. EVIDENCE: 58 Sambourne Road is a spacious detached property, within a residential area of Warminster. It is conveniently situated for local amenities, and also for public transport links to other centres. Service users are able to access a wide range of facilities independently. The property is owned and maintained by New Era Housing Association. It is decorated and furnished to a good standard, and provides a comfortable and homely feel. All service users have single bedrooms. One of these is on the ground floor. Each bedroom has a handbasin, but there are no other en-suite facilities. There is a shower downstairs, and a bathroom upstairs. An additional separate toilet is situated off the half landing from the staircase. The main communal space is a lounge with dining area on the ground floor. A spare room upstairs is designated as a ‘quiet room’, and is used by service Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 19 users for hobbies and activities. Downstairs, there is also a kitchen, a utility room, and the staff office, which is also used by the person sleeping in at night. The home has areas of garden at both front and rear. The front is in the process of being tidied up, with the removal of overgrown plants. External contractors have carried out this work. The plan now is for service users to take on this area. The rear is paved, and provides a pleasant courtyard feel. None of the service user group smokes, and the home is a designated nonsmoking area. The home was clean and hygienic in all occupied areas seen during this unannounced visit. Service users participate fully in keeping it this way. Rotas allocate various cleaning tasks amongst the group. A problem had developed in the vacant bedroom. During the period that the house was unoccupied over Christmas, damp had taken hold. Extra ventilation is to be installed in the loft, and the room will then be redecorated. All furniture in the room is to be replaced as well. As the room is not currently in use as service user accommodation, no requirement was set. The home is aware that the room must not be occupied unless and until it is made habitable again. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Service users are supported by suitable numbers of appropriately trained staff. Service users are protected by effective recruitment practices. Staff are supported and supervised effectively, enabling them to deliver a service that meets people’s needs. EVIDENCE: Staff to service user ratios are in keeping with the assessed ability levels of the group. Recently funding has been secured for a number of additional hours per week, in respect of a particular service user. There is agreement with the funding authority about how these hours are deployed, allowing them to be spread across the rota. There is always one person on duty, and there will usually be two staff during the daytime, depending on what service users are doing. There are two staff present between 3 p.m. and 7 p.m. One person then remains on duty, and sleeps in overnight. The home has a very active service user group, who are out and about to various activities, including in the evening. This means that having one member of staff present in the home is usually sufficient to respond to any needs that may arise. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 21 There has been some staff turnover since the previous inspection, and adjustments have also been made to cover maternity leave for a couple of employees. There is a mixture of full and part-time staff, allowing for flexibility in drawing up rotas. Mencap also has a pool of relief carers, who can be called upon to help maintain cover when necessary. There are two people from this group who are used most frequently, which helps to maintain consistency and stability for service users. There are clear records for the staff training which is provided. This begins from the first stages of someone’s employment. Induction and foundation training is linked to national standards for the social care workforce, and provides a pathway into National Vocational Qualifications (NVQs). New staff are ‘mentored’ via the close supervision of the home manager, or another senior support worker. Induction covers in-house topics, alongside Mencap’s organisational approach. New staff are appointed on an initial six month probationary period, and will not be confirmed in post until all induction and foundation stages are completed satisfactorily. Training covers all mandatory topics, such as first aid, food hygiene, and health and safety. Mencap training for all staff also incorporates sessions on the values of care, communication, and the protection of vulnerable people. Beyond this, training is provided on any topics relevant to the needs of the home’s service users. Staff can also access courses which may be helpful to their job role, such as developing their computing skills. Both of the home’s full-time support workers, along with one of the relief workers who is used frequently, have obtained NVQ Level 3 awards. This brings the home above the minimum 50 target for people with such qualifications. Another support worker is studying towards NVQ Level 3, and is due to complete this shortly. One more person is also to start the award. Other employees are still working through their initial induction and foundation. Recent recruits to the team at Sambourne Road have previously worked there as relief staff. They are therefore known to service users, who were consulted for their views about the appointments. As existing Mencap employees, the transfers to Sambourne Road were actioned through Mencap’s human resources department. The home’s registered manager checked out with each person’s previous line manager whether there were any relevant issues to take into consideration before confirming the move. Three staff files were sampled. These show that all required recruitment checks are carried out. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 The registered manager is suitably qualified, competent and experienced, so that service users benefit from a well run home. Quality assurance measures underpin service developments, and include actions based on the views of service users. Effective record keeping is maintained, upholding service users’ best interests. Service users’ health and safety are protected by the systems in place. EVIDENCE: The registered manager for 58 Sambourne Road is Mr Byron Nadgie. He has achieved the relevant qualifications now required of holders of this position, and has also gone on to undertake further studies in operational management, at NVQ Level 5. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 23 Quality assurance measures include systems for obtaining feedback from service users, their relatives, staff of the home, and other stakeholders. Surveys are carried out annually, inviting responses on a range of topics. These findings are then collated to identify any themes for action. The last survey produced positive responses across all indicators which were measured. There is also a range of regular audits of the various aspects of service delivery. Records are kept in-house to demonstrate that these are carried out. A senior Mencap manager carries out monthly visits to report on the conduct of the home, as required under care homes legislation. There is also quarterly monitoring of all key systems, based around three month development plans. These documents set out improvement tasks, who is responsible for the identified actions, and when they are to be completed. Development plans identify goals under a range of headings. This includes objectives based on service users’ desired outcomes. Current development plans have a strong focus on promoting greater input of service users to all aspects of the running of the home. For instance, involving them in audits of the home; developing their participation in their own care planning and record keeping; and increasing their input to management tasks such as the administration of petty cash, and the drawing up of staff rotas. As part of the developing quality process, there are to be four in-house management meetings per year, which will involve both service users and staff. These will focus on the service development plan. There is to be a person-centred approach, generated from the wishes of service users. A range of statutorily required records were checked during this inspection, and seen to be maintained appropriately. The home has made some changes to its practice in service user records, in response to recommendations of the previous inspection. Daily diaries are now in use for any notes regarding individuals, so that each record is maintained separately. The staff communication book is used to direct people’s attention to these, if necessary. Health and safety is given high priority, and various systems are in place to reflect this. There is a documented monthly workplace safety audit. Any issues highlighted are addressed as appropriate. Records show that any necessary services and repairs are carried out by relevant external contractors. For instance, testing of all portable appliances for electrical safety was carried out on the day of this inspection visit. There are also regular checks conducted and recorded in house by staff, on issues such as water temperatures. A range of general risk assessments support the health and safety practices in the home. The property was inspected by the fire safety officer in 2005, and was judged to be complying fully with all necessary steps at that time. At this inspection, all required tests and staff instruction were recorded as being carried out and Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 24 up to date. If faults are identified, these are reported and resolved. Fire drills and evacuation practices are carried out quite frequently, usually once a month. This is to ensure that all service users are fully aware of how they need to respond in an emergency situation, and supports risk judgements about their ability to be at home without staff supervision for some short periods. The property’s fire risk assessment was most recently reviewed in April 2005. This followed a full workplace risk assessment, which was carried out by Mencap’s health and safety advisor. Health and safety topics are covered in staff training. The home is also working with service users to promote their awareness of such issues. A video is to be made based around their ideas on the topic. Service users have already participated in the making of a leaflet about fire safety. Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 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 N/A 3 3 4 N/A 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 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 3 3 3 X X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X 3 X 3 3 X Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 26 No 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. Standard Regulation Requirement Timescale for action 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 Sambourne Road (58) DS0000028356.V277881.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 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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