Inspection on 10/03/07 for SCIC - 184 Drayton Avenue

This inspection was carried out on 10th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

SCIC - 184 Drayton Avenue 08/10/07

SCIC - 184 Drayton Avenue 19/01/06

SCIC - 184 Drayton Avenue 24/08/05

SCIC - 184 Drayton Avenue 30/03/05

SCIC - 184 Drayton Avenue 22/07/04

SCIC - 184 Drayton Avenue 21/02/04

SCIC - 184 Drayton Avenue 18/11/03

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 SCIC - Drayton Avenue, 184 184 Drayton Avenue Stratford On Avon Warwickshire CV37 9LD Lead Inspector Sheila Briddick Key Unannounced Inspection 10th March 2007 09:30 SCIC - Drayton Avenue, 184 DS0000004467.V324503.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 SCIC - Drayton Avenue, 184 DS0000004467.V324503.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. SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service SCIC - Drayton Avenue, 184 Address 184 Drayton Avenue Stratford On Avon Warwickshire CV37 9LD 01789 298709 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) Stratford & District Mencap Mrs Alexandra Louise Arnold Care Home 3 Category(ies) of Learning disability (3) registration, with number of places SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. NVQ Level 4. The Registered Manager achieve qualifications in both management and care including the Registered Managers Award, by 2005. Learning Difficulty Award. The Registered Manager pursues a professional qualification in the field of learning difficulty by undertaking the Learning Difficulty Award Framework level 3 by 2004. Successful completion of above awards. The Registered Manager to notify the National Care Standards Commission upon successful completion of the above and immediately in the event that the Registered Manager fails to achieve it or that the Registered Manager ceases, for whatever reason, to undertake the stated training. 19th January 2006 Date of last inspection Brief Description of the Service: Drayton Avenue is a three bed roomed semi-detached house which offers longterm accommodation for adults who have learning disabilities. The house has a lounge, dining room, kitchen, toilet and utility room on the ground floor. On the first floor it has three bedrooms, a bathroom and a staff sleeping in room. It has an open front and enclosed rear garden and is situated on the outskirts of Stratford on Avon within a large estate of social housing. The town centre is accessible by bus. The current scale of charging is £598.17. Additional costs that have to be met by service users include toiletries, chiropodists, outings, holidays, club activities, horse riding and magazines. SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the inspection visit the manager had forwarded to the Commission a pre-inspection questionnaire, a staffing rota, training records and menu records for the home. Service user and relative questionnaires were sent out however none were returned. All pre-requested documentation returned was examined as part of the inspection process and the evaluation included in this report. The inspection visit was unannounced and took place on Saturday, March 10, 2007 at 02.00 pm and ended at 3.15pm. The inspection involved: • • • Discussions with a service user and the carer on duty at the time. Observation of working practices and of the interaction between the service user and staff member. One service user was identified for close examination by reading their, care plan, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for service users. A tour of the environment was undertaken, and home records were sampled, including staff training, health and safety, rotas, quality assurance records and fire records. • I would like to thank the service user and staff for their hospitality and cooperation during the inspection visit. What the service does well: The people living in this home are supported by a fully committed staff team to lead purposeful and fulfilling lives as independently as possible. They are able to make their own decisions about what they want to do and to take risks in their daily lives. Service user’s rights and responsibilities are promoted properly in the care planning process and they are involved in the decisions being made about their future, their safety and their health-care. SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 6 The service aims to ensure that service users have a good understanding of decisions being made about them and information about life in the home and as part of this all care plans, care records, policies and procedures are available to service users in symbol and large print formats. People living in the home are encouraged to see it as their own. It is a very well maintained, attractive home and has very good access to the community facilities and services. Comments from service users included; • • • • I wanted to come and live in this home. I am very happy. The home is always clean and fresh because I help to keep it clean. I am happy and enjoy my life. 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. SCIC - Drayton Avenue, 184 DS0000004467.V324503.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 SCIC - Drayton Avenue, 184 DS0000004467.V324503.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): Standards 1 and 5. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Information about life in the home is available to prospective service users in symbol and large print format, which would enable them to make a decision about living in the home. Service users can be sure that they will have an up-to-date written contract in a style that enables them to understand their rights and responsibilities when living there. EVIDENCE: There have been no new people admitted to the home for some time and therefore outcomes for any new person coming to live in the home could not be assessed. In the event of a prospective service user wishing to come and live in the home however they would have sufficient information in the statement of purpose and service user guide to enable them to make a choice about living there. The Statement of Purpose and Service User Guide are in symbol and large print format, which would further support a prospective service user’s understanding of the services in the home. SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 9 The service user whose care was being looked at had an up-to-date contract on their care plan file, which had been signed by them. The information on the contract was in symbol and large print format, which was appropriate to the service user’s communication, needs and would support the understanding of their contractual agreement with the service. SCIC - Drayton Avenue, 184 DS0000004467.V324503.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): Standards 6, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home are involved in decisions about their lives and are playing an active role in planning their care and the support they receive to meet identified needs. EVIDENCE: The care plan for the service user whose care was being case tracked was looked at with their permission. The care plan was in the newly introduced style entitled, This is My Service Plan, which has a summary at the front of the care plan in large print and symbol format to assist the service user’s understanding of the content of the document. The service user’s assessed needs had been identified and care plans were in place for each need and an action plan of how the objective was to be achieved. There was clear guidance in the action plan for staff to follow to ensure that needs would be met safely and care would be consistent. SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 11 It was noted that on each care plan for the service user their specific dementia care needs had been considered and staff had guidelines how to support the dementia care needs alongside other care needs that had been identified. This is good practice in care planning and the key worker is to be commended for this. The service user’s changing needs due to their dementia has been monitored closely and this has included a referral for a social worker assessment, advice and guidance through the referral process from a dementia consultants and communication advice regarding dementia from speech and language therapists. A multi-disciplinary review was held in November 2006, which included family members of the service user, and planning is now taking place for the service user to move to a more suitable environment that will meet their changing needs. Staff said that the service user is beginning to make visits to their planned new environment and that the people they will be living with are already known to them. Service user meetings are conducted with them on a monthly basis and records looked at show that they are always asked if they know who to talk to if they are not happy and whether they feel they are allowed privacy and time alone. The record shows that home issues are discussed with them and their responses are recorded in the house meeting minutes. A staff member said, We have meetings with service users together and we ask for individual comments however, if the service user wants to say something in private to us they have the space to do so. Independence is promoted strongly within the home and this includes management of service user’s money. The support a service user requires in managing their finances is documented on their care plan. Care plans show that risks for individuals have been identified and staff have clear information on the care plan how risks can be minimised. Risk assessments are in symbol format, which enable service users to understand the risks they may encounter during their daily activities, and in the community. SCIC - Drayton Avenue, 184 DS0000004467.V324503.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): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home are supported to make choices about their lifestyle and to develop life skills. Daily activities promote independence and opportunity for people to live ordinary and meaningful lives in the community where they are living. EVIDENCE: One service user was at home at the start of the visit and they had just returned from having their lunch out. There are two other people who live in the home, one person was out shopping and the other was spending the weekend with their family. The service user at home, and staff, talked about the activities that people enjoy and this included their day services, attending craft clubs and a Fab SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 13 Club, (which is for more able service users), Getaway Club, walking and shopping locally. Care plan diaries show that each service user has a particular household task that they are responsible for and they have chosen these themselves during resident meetings. Comments received from service users on pre- inspection information requested included: I go horse riding on Thursdays. I visit my mum some weekends and some Saturdays my mum visits me here. I visit my boyfriend and I go to the pub with some of the of the care workers. In the evenings I sometimes like to have a quiet time in my bedroom. I am happy and enjoy my life. Staff spoken with said that one of the things they feel they do well as a team is supporting service users to get out and about. The care planning for the service user whose care was being ‘tracked’ also included a care plan for promoting their personal values, beliefs and relationships. The care plan was very clear with guidance to staff for supporting the service user with a long-term relationship they have and to follow their religious belief. Although a mealtime was not observed pre-inspection information received regarding the food provision in the home showed that food provided is nutritious and well-balanced. All food being stored in the kitchen looked fresh and was well within the use by date SCIC - Drayton Avenue, 184 DS0000004467.V324503.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): Standards 18, 19, 20 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people in this home receive is based on their individual needs. Staff working in the home have a high regard for promoting the respect, dignity and privacy of service users. Medicine management could be improved upon so that service users can be sure that medication records are up-to-date. EVIDENCE: There was significant evidence on the care plan looked at that the service user’s right to good-quality physical and mental health care is being promoted, including independence when possible. This includes seeing their GP, psychologist, dentist, optician and chiropodist. There is evidence that continence advice has been sought and the service user has opportunity to access screening clinics and to have flu vaccination each winter. The service user whose care was being looked at was quite happy to talk about their specific health care needs and was obviously fully informed about the changes taking place regarding her mental health care. They said that they SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 15 visit the doctor and nurse regularly and commented, I used to forget things but Im getting better, it must be the tablets. Service user’s consent is sought for the management of their medicine. The consent form is in symbol and large print format, which enables the service user to understand why they are having their medicine and what this, will be. Examination of medication administration records, (Mar Chart), the medicine cabinet and discussion with staff on duty at the time indicate that generally medicine is managed safely for service users. Staff must be mindful however to ensure that the record is maintained of the quantity of all medicines in the home and to date all creams when they are opened. The home has reviewed its medication storage and a single locked cabinet is now in place for the storing of medicines only. A care plan document has been devised, in symbol and large print format to record the wishes of service users in the event of the death. Staff on duty at the time demonstrated an understanding of the importance of documenting this information and also of the sensitivity of the issue being discussed. SCIC - Drayton Avenue, 184 DS0000004467.V324503.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): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in this home are able to express their concerns and know whom to speak to if they are unhappy or feel unsafe. They are supported by a staff team who have a good knowledge of how to respond to any suspicion of abuse. EVIDENCE: Pre-inspection information received informed that there have been one complaint about the service of the home since last inspection and that this was responded to satisfactorily. The commission has received no complaints about the home in the last 12 months. Service users reported on pre-inspection information they felt safe and would know whom to talk to if they were unhappy. Comments included; I would speak with our boss, or David, (Registered Provider) if I was not happy. I would speak with David, Ali Arnold or Pam if I was not happy or wanted to make a complaint. I would talk to one of the staff if I was not happy or wanted to make a complaint. SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 17 The relative who responded to pre-inspection information informed that they had never had reason to make a complaint. Service users have access to a complaints policy, which is in symbol and large print format and includes information about the Commission for Social Care Inspection. An adult protection procedure is in place at the home to inform staff of the appropriate measures to take to report any suspicions of abuse and this includes information for staff on the managers contact details. Staff spoken with confirmed that they had been provided with prevention of abuse training at various times. They said that Whistleblowing and Protection of Vulnerable Adult information is included in their induction training. SCIC - Drayton Avenue, 184 DS0000004467.V324503.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): Standards 24 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The appearance of this home creates a comfortable, safe and homely environment for the people living there. EVIDENCE: There is a warm and welcoming atmosphere in the home and at the time of the visit it was homely, comfortable and safe. People living there are able to move around easily and freely and to go to their bedroom to rest if they wish. Decor, furnishings and fittings were all clean and to a high standard. Comments received from service users indicated that they were happy with their environment saying: The home is always clean and fresh because I help to keep it clean. I buy flowers sometimes. SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 19 The shower room was clean and adapted to meet the mobility needs of one service user following an occupational therapist assessment. The laundry, which was domestic in style, was clean and in good order. There are established policies and procedures in place for the control of the risk of infection in the home and staff practices during the visit were seen to be safe. Infection control training is included in mandatory training for all staff. The garden looked well attended and the lawn had recently been cut. The staff team are to be commended for the support they give to service users to ensure that the home is maintained to a standard that enables service users to live in comfortable and safe surroundings. SCIC - Drayton Avenue, 184 DS0000004467.V324503.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): Standards 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in this home are protected by robust recruitment practices and supported by a skilled and competent staff team. EVIDENCE: Observation of care practice and discussion with staff on duty at the time determined that positive relationships existed between the service user at home and the staff supporting them. Staff were seen to be approachable by, and comfortable with the service user, they were good listeners and communicators, and were interested and committed to the work they were doing. Staff spoken with felt they had the skills and experience necessary for the tasks they were expected to do and this included Learning Disability Award Framework training and achieving an NVQ at Level 3. Pre-inspection information indicates that staff can access training in specialist needs including dementia and epilepsy. SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 21 There is a rolling programme of assessment of care staff towards an NVQ Level 2 or above and pre-inspection information received informs that seven staff have an NVQ at Level 2. Staff spoken with said they had regular supervision and staff meetings. They said, “ Team working is very good, we communicate well. We hope people feel safe here. Discussion with staff and examination of the staffing rota shows that there continues to be appropriate staff support for the people living in the home. The home is closed during the day most days while service users attend day services, however when service users are at home the manager seeks to provide two staff on duty, usually at weekends, to enable people to get out when they wish to do so. Pre-inspection information looked at indicated that the recruitment of staff is thorough and includes seeking Criminal Record Bureau Disclosures and obtaining two written references. SCIC - Drayton Avenue, 184 DS0000004467.V324503.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): Standards 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users continue to benefit from a well run home. They are able to express their views of the service provision and know that their views will be listened to and acted upon. EVIDENCE: Discussion with staff and the manager, examination of home records and observation of care practices demonstrated that the service is managed by a competent and skilled manager who fosters an atmosphere of openness and respect with service users, their friends and that staff feel valued and their opinions matter. Health and safety management in this home is to a high standard and all records relating to this were up-to-date and in good order. Safe practices SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 23 were observed in the home and records showed that this is further promoted through training for staff in manual handling, food hygiene, first aid, fire safety and infection control. Staff have clear instruction regarding the use security and safety items in the home. Staff spoken explained the procedure for recording any circumstance when the security system on the front door is used. Pre-inspection information received shows that maintenance of fire fighting equipment, electrical appliances and central heating systems takes place on a regular basis. Excellent systems are in place for ensuring that food hygiene is maintained and monitored, this includes recording fridge and freezer temperatures and cooked meats. Fire safety management includes regular testing of fire alarms and emergency lighting and all records relating to fire safety management were up-to-date and in good order. A record is maintained in the home of any accident or incident that happens to a service user. All records seen during this visit were stored securely and in good order. SCIC - Drayton Avenue, 184 DS0000004467.V324503.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 4 2 N/A 3 X 4 X 5 4 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 3 3 X 4 X X 4 X SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 25 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. 1. Standard YA20 Regulation 13(2) Requirement The registered manager must ensure records of all medicines held in the home are up to date and that ointment jars and tubes are dated when opened. Timescale for action 30/04/07 SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The work must continue with service users in identifying the needs and wishes in the event of their death. SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 SCIC - Drayton Avenue, 184 DS0000004467.V324503.R01.S.doc Version 5.2 Page 28 - 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!