Inspection on 05/02/07 for SCIC - Stratford Road, 29

This inspection was carried out on 5th 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

SCIC - Stratford Road, 29 20/12/05

SCIC - Stratford Road, 29 27/07/05

SCIC - Stratford Road, 29 18/03/05

SCIC - Stratford Road, 29 26/10/04

SCIC - Stratford Road, 29 27/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 SCIC - Stratford Road, 29 29 Stratford Road Shipston On Stour Warwickshire CV36 4AZ Lead Inspector Kevin Ward Key Unannounced Inspection 5th February 2007 07:55 SCIC - Stratford Road, 29 DS0000004491.V329410.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 - Stratford Road, 29 DS0000004491.V329410.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 - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service SCIC - Stratford Road, 29 Address 29 Stratford Road Shipston On Stour Warwickshire CV36 4AZ 01789 298709 01789 296724 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 Ms Julia Furniss Care Home 3 Category(ies) of Learning disability (3), Physical disability (0) registration, with number of places SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2005 Brief Description of the Service: The home provides respite care in a bungalow with three single bedrooms, a shower, two toilet rooms, a kitchen/diner, lounge, staff sleeping in room/office and a garden. It was built in the 1930s on what is now a busy road through the village. The service provides opportunities for adults with a learning disability to develop life and social skills and some degree of self-management. The bungalow stands on the same plot as another care home run by the same organisation for five residents and shares the same manager, staff group and semi circular drive. SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was the first inspection to take place this year (April 06 – March 07) and focused on assessing the main key Standards. As part of the inspection process the inspector reviewed information about the home that is held on file at the Commission, such as notifications of accidents and incidents. A pre inspection questionnaire was also sent to the manager to complete to provide more information about the home. The inspection included meeting with a person who was using the service at the time of the inspection site visit. Six people and their relatives completed comment cards about the home and the information was used to help inform the conclusions of this inspection. The inspection also included case tracking three people that use the short breaks service. This involves looking at people’s care plans and checking how their needs are met in practice. Discussions took place with two members of staff who were on duty at the time of the site visit. A number of records, such as care plans and fire safety records were also sampled for information as part of this inspection. The service is funded by Warwickshire Social Services Department who do not charge for the service, with the exception of £3.90 per day for the cost of meals and expenditure on personal items and transport. What the service does well: People’s needs are assessed before they start to take short breaks at the home and their needs are recorded in their care plan / personal profile so that staff are able to meet their needs effectively. When they visit the home people are supported to maintain their personal routines and encouraged to retain their independence. People are enabled to venture out to the local shops and to take part in leisure activities that they are known to enjoy. The details of people’s GP’s details are recorded on their files so that help can be sought if necessary. The home makes appropriate use of guidance from health professionals to support safe practice, such as mental health guidelines and epilepsy management guidelines. People are told how to complain A person using the service confirmed that staff are helpful and said “ I tell staff if I have any problems or fall out with anyone and staff sort it out for me”. Staff have been provided with information and procedures for recognising and reporting any suspicions of abuse that may come to their attention. Satisfactory vetting procedures are in place to prevent unsuitable staff from being employed at the home, so that people are protected against potential abuse. SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 6 Overall the home is comfortable and well maintained and suitably equipped for the people that use the service. Staff are given access to a satisfactory range of training opportunities to enable them to carry out their work effectively. 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 - Stratford Road, 29 DS0000004491.V329410.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 - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed and they are provided with information and support to help them to settle into using the service. EVIDENCE: People’s files contain evidence that people’s needs are assessed by the home before they move in. This includes a written needs assessment, carried out by staff at the home and a Social Services Care plan. The people who use the service are placed there by Warwickshire Social Services Department and people’s files were seen to contain placement contracts detailing the service being purchased by Social Services. People are provided with opportunities to meet with staff and visit the service prior to stopping overnight, so that introductions to the service takes place at a pace that is in keeping with service users wishes. A person using the service confirmed that staff had helped her to settle into the home when she first started to use the service. A service user guide was seen in the home providing people with helpful information about using the short breaks service. SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 9 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are planned for and reviewed so that they receive the support they require to maintain their independence during their stays at the home. EVIDENCE: Three people’s care plans were sampled and several documents from other people’s files were viewed to check the information and advice that is available to help staff meet people’s needs. The care plans contain helpful summaries of people’s essential needs (care profiles), such as personal care needs and dietary needs and social interests. Good work has taken place to cross reference people’s care plans with their risk assessments and other guidelines where hazards have been identified, e.g. good guidelines were seen for the safe management of epilepsy and for supporting a person with mental health needs. People’s care plans and associated documents are signed by staff to confirm that the information and guidance has been reviewed and currently up to date. The person using the service at the time of the visit confirmed that she had seen her care plan and the member of staff on duty in the morning SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 10 demonstrated a good knowledge of people’s needs, as recorded in their care plans / personal profiles. People’s daily records are well formatted with separate headings that help staff to focus their attention on the matters detailed in people’s care plans, e.g. one person’s records highlighted the daily living tasks she had undertaken whilst at the home, in keeping with their goal to move into an independent living placement. The member of staff on duty demonstrated a good understanding of people’s needs, preferences and personal routines. A person using the service explained how she takes part in food preparation and other daily living tasks, indicating that she is encouraged to maintain her independence whilst using the service. Information contained in people’s care plans demonstrates that people are encouraged to take part in other light domestic chores whilst they are staying at the home to encourage their independence, e.g. make beds, set tables, make packed lunches An alarm has been fitted to the front door so that staff are able to respond to ensure the safety of one person, in the event they are inclined to leave the home without telling anyone. SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 11 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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to enjoy a satisfactory range of activities and to have access to the community. People are provided with meals that they like and that meet their dietary needs during their short breaks at the home. EVIDENCE: Comments by the people who use the service and their relatives (in comment cards) indicate that overall they are happy with the care and support provided by the home. A person using the service on the day of the site visit also spoke very highly of the friendly and kind support provided by staff. Entries in people’s records indicate that they are assisted to get out and about to the local shops when they visit the home. A person using the service verified that the home seeks to support people to take part in community activities that they enjoy, such as shopping, bowling and the cinema. A person using the service explained that she had been involved in a theatre trip over the SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 12 preceding weekend and had been assisted to shop for greetings cards and other personal items. Comments by relatives in comment cards confirm that they are kept updated and informed of important matters and are made to feel welcome by staff at the home. The contact details of people’s relatives are prominently recorded in the front of their files. A person’s care plan was seen to contain helpful information for staff to follow to assist them to maintain appropriate professional gender boundaries when supporting the person concerned. A member of staff confirmed that some staff have previously had sexuality and relationship training so that they are better equipped to support people with relationship issues. A person using the home on the morning of the inspection confirmed that staff are friendly and kind and show respect in their dealings with people. The person also confirmed that staff show a proper regard for people’s privacy, e.g. knock and wait before entering their rooms. Bedroom doors are fitted with safety locks so that people can lock their door behind them but can easily get out of their bedrooms without having to use a key. Recent menus were examined and were found to reflect the preferences and needs of people that use the service, e.g. the following week’s menu had been designed to take account of a persons need to eat soft foods. People’s food preferences and dietary needs are recorded in their care profiles. A person using the home said that she always gets to eat what the food she enjoys and that she takes part in some food preparation. Fresh fruit was available for people in a fruit bowl in the kitchen and a member of staff explained that staff shop for healthier food options when shopping for grocery items to encourage a healthy diet. SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 13 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to have their personal care and health needs met when they visit the home. EVIDENCE: As previously noted, people’s comments (in the comment cards that were completed as part of the inspection process) indicate that they are happy with the care and support provided by the home. A person using the service confirmed that staff are polite and friendly and enable her to carry out her normal daily living routines, e.g. domestic tasks and preferred leisure activities. People’s personal care needs and their preferences are detailed in their personal profiles to enable staff to support them in the manner like. An intimate care policy is in place to consider people’s privacy dignity and gender care issues. Comments by staff the person using the service confirmed that bedtimes are flexible and people are allowed to sleep in at the weekends if they wish to do so. The home does not offer a service to people with complex health needs and high support needs. Consequently none of the people using the service receive visits from community nursing services and there is no need for any health SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 14 protocols to be in place at the home for invasive procedures, e.g. administration of diazepam. People’s health needs are recorded in their care plans and where necessary additional guidance has been sought from other health professionals to assist staff to provide the correct care support, e.g. metal health support guidelines were seen to be in place for one person and guidelines for the safe management of epilepsy were seen for another person. The contact details of people’s GP’s are held on file so that they may be accessed in the event of an emergency during the person’s stay at the home. As the service provides a short breaks service the prime responsibility for people’s health care remains with the person themselves or their relatives. People’s parents / carers are required by the home to complete a form at the time of each new visit, detailing people’s current prescribed medication so that any changes that have taken place are made clear. People also have to bring a copy of their current prescription with them so that staff can check exactly what medication has been prescribed by the GP. This ensures that the home holds current information and is up to date with changes in medication that may take place between the times of people’s visits to the home. There were no controlled drugs held on site at the time of this inspection visit. A bound book with numbered pages is in place for the proper recording of controlled drugs. Two members of staff are correctly signing the record when medication is given out to properly account for all controlled drugs that enter the home. A risk assessment is in place for people who manage their own medication whilst staying at the home. People also sign a consent form agreeing to allow staff to monitor and check with them that they have taken their medication correctly, as an additional safeguard against administration errors. At the time of the site visit one person’s medication had been recorded into the home incorrectly. A second staff member had promptly picked up this error and the manager explained that she was taking action to investigate and remedy the problem. Two staff confirmed that only people who have had medication training are allowed to give out medication. The manager explained that staff are initially observed and monitored giving out medication before being allowed to give out medication unsupervised. The manager agreed to introduce a competency assessment to check with staff that they have fully understood the training on medication procedures. SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 15 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable procedures are in place for dealing with complaints and reporting suspicions of abuse so that the people living at the home are protected from harm. EVIDENCE: An organisational complaints procedure is in place for staff and an illustrated version of the complaints procedure has been provided to the people using the service. A log is in place for recording complaints at the home. There have been no complaints directly to the home or to the Commission for Social Care Inspection since the last inspection. Information contained in the six relatives comment cards that were completed as part of this inspection indicate that people have been made aware of the complaints procedure but have not had any reasons to use it recently. The manager has recently issued new booklets addressing the prevention of vulnerable adult abuse to staff at the home and said that she planned to use this as a discussion point with staff at a forthcoming staff meeting. A member of staff on duty explained that she had seen the adult protection and whistleblowing procedures as part of her induction training (Learning Disability Award Framework induction training) and knew how to report any concerns should this become necessary. There have been no adult abusive investigations held at the home since the last inspection. SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 16 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides suitably equipped, comfortable and clean accommodation for the people who use the service. EVIDENCE: 29 Stratford Rd provides ground floor bungalow accommodation for three people. Access throughout the home is even, making it accessible for people with mobility problems. There is also a good-sized walk in shower room, which is suitable for people with disabilities. However the design of the home and the limited size of some rooms mean that the home is not suited to meet the needs of wheelchair users. The kitchen units are old and the manager stated that there remains an intention to refurbish the kitchen in due course alongside plans to improve the laundry room / utility area. This is planned to coincide with the closure of the home as a short breaks service shortly, as this function will transfer to another premises. The organisation plans to re register the home for people with learning difficulties with dementia care needs. The lounge area is comfortable and cosy with sufficient seating in place for people to sit down together if they wish to do so. The bedrooms are adequately sized and SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 17 equipped to meet the needs of the people that the home is currently set up to support. An infection control policy is in place at the home and the training records indicate that the majority of staff have previously been provided with infection control training. The home was found to be very clean, well aired and free from any offensive odours. The laundry room is small but has the essential laundry equipment in place. SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 18 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): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are vetted before starting work at the home and are provided with access to a satisfactory range of training courses to equip them for their roles. EVIDENCE: The manager explained that due to staff maternity leave and sickness there have been pressures on the staff rota. This has been addressed by using staff from other care homes that are run by the organisation. The manager explained that the situation is now improving as staff are returning to work. The recent rotas show that commonly there is one member of staff on duty at the home and on some occasions this increases to two staff to enable people to get out and about at weekends. Additional support is available from staff in the home next door, set in the same grounds as the short breaks unit if required. A member of staff confirmed that a manager is on call at night and the contact details are available on the notice board in the office, in the event that such support is required. The manager has provided an audit record of staff recruitment checks for two staff recently employed at the home. This indicates that the home has thorough recruitment procedures in place and confirms that staff are required to complete Criminal Record Bureau or POVA first checks (list of people not SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 19 safe to work with vulnerable adults) before starting at the home. Copies of people’s references were also seen as further evidence that suitable vetting checks are carried out. In the pre inspection questionnaire the manager reports that 62 of staff hold National Vocational Qualifications (NVQ’s) at level 2 or above and that all staff have had first aid training. Comments by staff and information contained in the home’s training records indicates that staff are provided with access to mandatory Health and Safety related training courses, such as food hygiene and fire safety. The manager has provided written confirmation of plans to provide staff with updated training in all the mandatory training subjects during the course of the coming year in addition to providing more staff with sexuality, epilepsy and dementia care training to support good practice in these areas. SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall satisfactory arrangements are in place for ensuring a quality service and good systems are in place for maintaining a safe living environment for people. EVIDENCE: The manager has approximately 15 years experience of working with people with learning difficulties including 9 years as a manager. The manager also holds the Registered Managers Award and National Vocational Qualification, level 4 in Care and is well qualified for the role as Care Home manager. Last year the people who use the home were surveyed for their views. The outcomes of these consultations were summarised and where appropriate fed into service developments in the organisations development plan. The SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 21 manager reports that she intends to send out fresh questionnaires for people to complete again very shortly. An employee of the organisation is carrying out monthly monitoring visits and copies of the reports were seen at the home. The reports indicate that suitable arrangements are in place for monitoring the work of the home and provide an opportunity for the visitor to seek the views of people using the service and to check significant records, such as accidents, incidents and complaints. A Health and Safety audit is also carried out by staff on a regular basis and reports are held at the home. Any shortfalls that are identified are brought to the attention of the manager to address, e.g. repairs to equipment. Information provided by the manager in the pre inspection questionnaire indicates that suitable arrangements are in place for testing and maintaining the home’s equipment in safe condition. Entries in the fire safety log demonstrate that fire alarms and lights are tested at the correct frequencies and that fire drills are carried out at the home. Comments by a person using the service confirmed that she had been made aware of the procedure and had been included in fire drills. Records are in place to demonstrate that shower heads and de-scaled and flushed to reduce the potential hazard of legionella. The hot water monitoring record shows that the hot water in the home often exceeds 43 degrees centigrade when it leaves the tap. This is because the hot water outlets are not fitted with temperature regulator valves and the temperature in the boiler is set to keep the water hot enough to stop legionella developing. The manager said that she would put a risk assessment in place to ensure that people are not being placed at risk of scalding. SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 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 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 x 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x x x x 3 x SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 23 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 manager is required to introduce a written assessment to check that staff have fully understood the medication procedures, to further support practice. The manager is required to carry out a risk assessment of the likelihood of people being scalded by hot water at the home and put all appropriate safeguards in place to effectively reduce this hazard. Timescale for action 21/03/07 2 YA42 13 (3) (c) 07/03/07 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 Refer to Standard YA6 Good Practice Recommendations Proceed with plans to increase the involvement of relatives and social workers in reviewing people’s care plans. SCIC - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 24 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 - Stratford Road, 29 DS0000004491.V329410.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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