Inspection on 21/09/06 for Seymour Gardens (33)

This inspection was carried out on 21st September 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Seymour Gardens (33) 22/02/06

Seymour Gardens (33) 28/06/05

Seymour Gardens (33) 27/05/04

Seymour Gardens (33) 29/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Seymour Gardens (33) 33 Seymour Gardens Ilford Essex IG1 3LP Lead Inspector Ms Harina Morzeria Key Unannounced Inspection 21 September 2006 11:30a st DS0000025927.V311577.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 DS0000025927.V311577.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. DS0000025927.V311577.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seymour Gardens (33) Address 33 Seymour Gardens Ilford Essex IG1 3LP 020 8518 4645 020 8554 0396 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) Norwood Ravenswood East Ms Vanda Karen Brand Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000025927.V311577.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom residential accommodation with both board and personal care is provided at any one time shall not exceed 5. 23rd February 2006 Date of last inspection Brief Description of the Service: Seymour Gardens is a five bedded home for adults with learning and physical disabilities run by Norwood, a not-for-profit, Jewish organisation, providing services for people of the Jewish faith. Hence the ethos of the home is based around Jewish beliefs, customs and faith. Service users accommodated in the home have medium -- high dependency needs and may exhibit challenging behaviour. The home first opened in 1993 and is a converted domestic dwelling in a popular residential area in Ilford. It is close to public amenities as well as being served by good public transport links. All service users have their own bedrooms which are well furnished and decorated, with one of the downstairs rooms containing an en - suite facility. Appropriate communal space is provided and there is also a small well-kept garden, for the service users enjoyment. The manager and staff support service users to develop and maintain independent living skills, attend college for various courses as well as accessing community facilities locally and at the Leonard Seiner Centre (Jewish community centre) in Barkingside. Personal care is provided on a 24-hour basis, and health care needs are met by staff supporting service users to attend appointments with health professionals. The fees range from £3000 - £4,300 per month approximate. A Statement of Purpose and Service Users Guide are available to the service users and their representatives. DS0000025927.V311577.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 21/09/06 and was a key inspection as part of the inspection programme for 2006/2007. The inspector was shown around the house including service users’ bedrooms (with permission). Staff and service user records were examined. Service users were spoken to on the day of the inspection and were asked to give their views of the service and their experience of living at Seymour Gardens. Discussion took place with the registered manager. Care staff were asked about the care that the service users receive, and were also observed carrying out their duties during the visit. All the service users spoken to expressed satisfaction with the service provided at the home and the care they receive. An enforcement notice was issued on third January 2006 for breach of Regulations in relation to failure to carry out monthly Regulation 26 visits. At this inspection concern still remains that the registered providers have not been able to sustain the level of compliance required. The inspector would like to thank the manager, staff and the service users for their input and assistance during the inspection. What the service does well: During the inspection staff were observed providing service users with assistance and support and respected their right to make decisions. Staff support the service users to maintain family links inside and outside the home and their involvement is encouraged, with individual service users’ agreement. Service users physical health care needs are monitored and this ensures that service users’ needs are recognised and met. DS0000025927.V311577.R01.S.doc Version 5.2 Page 6 A wide range of activities are provided for each service user according to their capabilities, needs and wishes and service users are supported by staff to participate in these. The service users live in a clean and comfortable environment. 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. DS0000025927.V311577.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 DS0000025927.V311577.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgment has been made using the available evidence including a visit to the service. A detailed pre – admission assessment procedure is used to gather information about prospective service users to assess their needs. Prospective service users and their relatives are able to visit the home prior to their admission. Trial stays are offered before the service user decides if they wish to live there permanently. EVIDENCE: The organisation have developed a detailed pre - admission assessment procedure and a detailed pre - admission assessment is undertaken of all prospective service users by an admissions officer based at the organisation’s head office, who then refers the person to an appropriate home where the person’s needs can be met in discussion with the manager for the home. The registered manager is then able to confirm if they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. Evidence confirms that the assessment is conducted professionally and sensitively and involves the service user, their family or representative of the service user. DS0000025927.V311577.R01.S.doc Version 5.2 Page 9 The admission will only take place if the registered persons are confident that the staff have the skills, ability and qualifications to meet the assessed needs of the prospective service user. There have been no new admissions to this home since October 2002. The inspector is satisfied that the above process would be followed by the service should a vacancy arise. The files for three service users were examined. There was evidence on these files to show that the service users’ needs are re - assessed regularly and care plans are updated if they need to change. Family members and other professionals involved in the care of each individual service user are fully consulted and involved. DS0000025927.V311577.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 8,9,10 Quality in this outcome area is good. This judgment has been made using the available evidence including a visit to the service. Service users’ health, personal and social care needs are set out in an individual plan of care, and are detailed enough to provide staff with sufficient information about how to meet the service user’s individual needs on a day-today basis. Staff provide service users with assistance and support to enable them to make decisions about their own lives and appropriate risk assessments are in place. EVIDENCE: Seymour Gardens accommodates five service users all of whom are encouraged to be as independent as possible by staff. The service users require varying levels of assistance and prompting from the staff and this is duly provided. The care plans for three service users were examined. Staff and service users were asked about the care being provided. Each service user has an individual personal plan, which outlines the service users individual needs and how these will be met. DS0000025927.V311577.R01.S.doc Version 5.2 Page 11 Evidence was seen on the day of the inspection that the service users who were not involved in any regular activities were asked about what they would like to do. The service users spoken to confirmed this. The service users knew who their key workers were and said that they would talk to them or the manager or a senior carer if they had any problems. Evidence was seen on daily logs that staff prompt and assist service users to carry out tasks according to their capabilities and needs. Comprehensive risk assessments are in place for the different activities that service users take part in and service users are supported by staff to carry out their chosen activities, within this framework. Daily records showed that staff record what the service user has done every day which reflects their care plan and daily activity plan. The individual personal plans are reviewed regularly and updated to reflect changing needs. The service users are encouraged to attend the reviews and participate in the review process. An organisational confidentiality policy is in place and service users know that they can have access to their information and that any information held about them will be handled appropriately and that their confidences are kept. DS0000025927.V311577.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12,13,14,15,16,17 Quality in this outcome area is good. This judgment has been made using the available evidence including a visit to the service. Service users have opportunities for personal development and are able to take part in age, peer and culturally appropriate activities. The home is particularly good at being able to meet the cultural and religious needs of people from a Jewish background. Service users’ rights are respected and responsibilities are recognised in their daily lives. Service users enjoy their meals and are asked on a daily basis to choose from the menu which they have already agreed. EVIDENCE: The service users were asked their views, and the lifestyle of the service users was observed as well as care plans being examined. Most of the service users attend college, and participate in activities in the community and at the local Jewish community centre Leonard Seiner Centre. Service users go out to the cinema, bowling and participate in various other daily activities including swimming, going to the gym, music and movement, shopping, eating out and going to the pub. The daily routine is set by the DS0000025927.V311577.R01.S.doc Version 5.2 Page 13 activities that the service users are involved in, which are outlined in their daily activities plan. One service user attends college for a computer course and a computer has been purchased for all the service users to develop this skill. The service users confirmed that they do the activities that were listed on their activity plans. An external paid tutor comes to the home twice a week to conduct story telling sessions, which was taking place on the day of the inspection and thoroughly enjoyed by all the service users. The activity plans show that these routines promote individual choice and freedom of movement. Staff support individuals to pursue their own interests and hobbies. Two volunteers visit the home to carry out cultural led tea parties, with the service users, holding discussions about forth coming Jewish festivals listening to music and dancing. Sessions are held for staff to enhance their knowledge and understanding of forthcoming events so that they can provide care and support according to Jewish custom and tradition. These take place at the Leonard Sainer Centre, with service users’ input, where a number are keen to participate in making appropriate cards, decorations and foods. Staff support the service users to maintain family links and friendships inside and outside the home and their involvement is encouraged, with individual service user’s agreement. One of the service users regularly spends weekends at home and contact with the families of the other service users is encouraged and supported by staff. One service user is regularly taken by staff to visit her mother who is accommodated in a residential home and visits from her to the home are also encouraged. Relatives and friends are able to visit at any time and no restrictions are placed on visiting times. No relatives were visiting at the time of the inspection. Meals are recorded on a daily form and there is a menu set for each week. Service users spoken to stated that they enjoyed the food and are offered a choice on a daily basis. On the day of the inspection the inspector, staff and some of the service users sat together to have lunch which was individually chosen by the service users and was wholesome. The service users often help staff to prepare meals and go shopping with them to purchase any particular ingredients needed. Special diets are catered for, especially the provision of kosher diets in line with Jewish faith and customs. Staff are aware of individual likes/dislikes and were aware of service users who have special dietary needs. DS0000025927.V311577.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The medication policies and procedures are clear and the staff have received training to ensure safe administration of medication to the service users. Service users’ physical health care needs are monitored which ensures that service users’ needs are recognised and met. EVIDENCE: All the service users residing at Seymour Gardens require varying levels of support but cannot manage to carry out their own personal care hence needing prompting and total assistance from staff. Service users’ physical and emotional health needs are met by staff who understand their needs and provide appropriate assistance as required. All the service users have their own G.P. The care plans identify areas where staff input is required. One service user is well supported by staff as he is regularly screened at Moorfields eye hospital for specialist attention as well as seeing a dermatologist. DS0000025927.V311577.R01.S.doc Version 5.2 Page 15 Organisational policies and procedures for the handling and recording of medicines in the home are available. The majority of staff have received an appropriate level of training as part of the induction programme. The care plans were examined and records of referrals to specialist healthcare professionals and appointments were being kept. Records examined showed that service users are seen by dentists, opticians, chiropodist, district nurses, dietician and doctors as and when required. Staff also support service users to attend outpatient clinics. A record is maintained of the current medication for each service user and the staff working in the home have received updated medication administration training. None of the service users administer their own medication as they are not able to do so. Medication administration records were observed to be appropriately completed. The manager is aware that each service user’s photograph should be attached to his or her medication record for ease of identification. DS0000025927.V311577.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The manager and staff make every effort to sort out any problems and concerns. All complaints and issues of concern must be recorded with outcomes in the complaints book so that the service users and their relatives feel confident that their complaints are listened to and will be acted upon. All staff working in the home have received training in adult protection/abuse awareness to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: There is a written policy and procedure for the protection of vulnerable adults and whistle blowing. All newly recruited staff receive abuse awareness training during their induction training. Evidence was seen that most staff have repeated the above training and two new staff are due to complete this training. The staff spoken to as part of the inspection process, confirmed that they have completed adult protection training and were clear as to their responsibilities to report any potential abuse and of what the reporting lines should be. The complaints procedure is also available in pictorial format and the service users spoken to confirmed that they would know the procedure to follow should they have a complaint. No complaints were recorded in the complaints log. The manager is aware that all complaints must be recorded in the complaints book with the outcomes so that any patterns of complaints can be identified and appropriate action may be taken to prevent similar occurrences. DS0000025927.V311577.R01.S.doc Version 5.2 Page 17 DS0000025927.V311577.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29, 30 The quality in this outcome area is good. This judgment is made using the available evidence including a visit to the service. The home is comfortable, clean and hygienic which enhances the well-being of the service users. Service users like their bedrooms which are suitable for them and promote their independence. There are sufficient toilets and bathrooms providing privacy however a suitably adapted bath is required and must be available to meet individual needs. Sufficient shared space is available in the home. EVIDENCE: The home was clean and free from odours throughout. Individual care plans and daily records show the importance of stressing personal hygiene to the service users for example washing hands frequently. The inspector was shown around the house by the manager. All the service users bedrooms were viewed with their permission. The bedrooms are DS0000025927.V311577.R01.S.doc Version 5.2 Page 19 individually decorated and filled with personal possessions. Service users spoken to said that they liked their bedrooms and felt comfortable and safe in them. As highlighted during the previous inspections the bathroom upstairs is required to be adapted to meet the needs of one of the service users who now has difficulty accessing it. The manager has sought an O.T. assessment before any adaptations are made. However there are difficulties in installing the equipment which was recommended by the occupational therapist due to limited space in the bathroom. The manager continues to explore alternatives but is required to make a decision quickly in order to ensure that all the service users’ needs are met equally. See requirement. The lounge and dining area were bright and clean and provide sufficient space for the service users to enjoy. There is a small garden at the back of the house which is accessed via the dining area. It is well maintained and a safe area for service users to enjoy during fine weather. DS0000025927.V311577.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32,33,34,35,36 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home employs staff in sufficient numbers, to meet the needs of the service users. There is an organisational procedure for the recruitment of staff, which is robust and provides safeguards for people living in the home. EVIDENCE: The organisation continue to recruit staff from overseas , mainly the Philippines, who undergo a twelve week induction programme and shadow the existing staff group, which assists their learning and development before working on shifts. All the staff have job descriptions and are aware of their own responsibilities and the management structures. There was one vacancy ( support worker Level C) at the home at the time of the inspection. The staff are competent and qualified to do their jobs and are selected from a qualified group of applicants who have experience of working with people with multiple disabilities in their country of origin. All staff recruited from abroad work for a six-month probationary period and under go all the relevant training via the organisation, before enrolling on NVQ level 2 and 3 courses. On the day of the inspection, the inspector spoke to three staff members who confirmed that they have received thorough induction training and continue to attend relevant training courses provided by the organisation. Evidence of staff DS0000025927.V311577.R01.S.doc Version 5.2 Page 21 having completed a variety of training was seen on the individual staff files. In discussion with staff, it was evident that they fully support the main aims and values of the home. Staff have developed a good knowledge and understanding of the Jewish culture and faith via the induction programme and ongoing training provided by the organisation. Service users said that the staff are kind and caring towards them and know what they need. The manager was satisfied with the level of staffing provided at the present time and the use of peripatetic staff has been reduced. The manager acknowledges that permanent staff provide continuity and consistency to the service users which is vital for their safety and security. Staff records were examined and showed that service users are supported and protected by the organisation’s recruitment policy and practices. Staff supervision is taking place and all staff are having formal supervision with the manager and the senior support worker. Training records were also examined and showed that staff are given the opportunity to attend ongoing training as part of effective service delivery. The staff files to be organised in a way which provide information easily. DS0000025927.V311577.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39,42 The quality outcome in this area is good. This judgment has been made using available evidence including a visit to the service. The manager is an experienced and qualified person. The home is run in a way which ensures that the service users’ best interests are safeguarded by the home’s recordkeeping. Staff are aware of the lines of accountability and monitoring systems within the home are robust enough to ensure that the manager is fully appraised of any issues relating to the day-to-day running of the home and the specialist needs of the service users. EVIDENCE: The current manager has managed the home since 2001 and is experienced to carry out her role. She has completed the Registered Managers Award and the NVQ level 4 course. The home is run in a way which provides a safe environment for the service users and staff. The service users’ health, safety and welfare are met by the staff working in the home. DS0000025927.V311577.R01.S.doc Version 5.2 Page 23 All records are held securely. Service users would be able to have access to their records. All accidents are recorded and appropriate action is taken when required. Induction training for new staff is being achieved with further ongoing training being offered. Health and safety checks and the associated records were appropriately completed in line with the Regulations. Individual risk assessments for each service user are in place. A statutory requirement notice was issued on 3rd January 2006 for failure by the responsible individual to undertake monitoring visits to the home in compliance with the Regulation 26 of the Care Home’s Regulations 2001. Since the issuing of this notice the registered individual did comply with this Regulation. However, the responsible individual has failed to carry out monthly visits at Seymour Gardens since June 06. Discussions have been held with the responsible individual reinforcing the Regulation under which these visits are required to be conducted, and the obligation of the organisation to monitor and report on the quality of the service provided in the home. These reports must be made available to the commission promptly. A requirement has been made and the CSCI will consider further enforcement action. The inspector was informed that lay monitoring visits are regularly undertaken by lay monitors appointed by Norwood and one of the representatives of “relatives of the Parry group” which is a group of parent representatives. An auditor appointed by the Organisation carries out regular financial audits. However, an annual quality assurance review of the whole service should take place, about the operation of the home. The opinions of service users, relatives and any health professionals as well as other representatives involved in the care of the service users must be sought. This quality audit should be analysed and the findings should be annually reported on and also form part of the Service Users Guide. The inspector was informed by the responsible individual that as part of this process a user lead focus group called “people first” has been formed to seek the views of the service users, indicating that this process has begun. No service users from Seymour Gardens attend these meetings at present. The requirement relating to quality assurance has been re - iterated. DS0000025927.V311577.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 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 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 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 2 2 3 3 3 3 DS0000025927.V311577.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA22 Regulation 22 Requirement The registered person is required to ensure that a record is kept of all complaints/issues raised, outlining the investigation process and the outcome and action taken. Timescale for action 30/11/06 2 YA27 23 The registered person is required 30/11/06 to ensure that adequate bathroom adaptations are made in order to ensure that all service users can access the bath with ease. Previous requirement not met 30/06/06. The registered individual must ensure that monthly monitoring visits are carried out as is required by regulation and the reports are made available to CSCI. 30/11/06 3 YA38 17/18 4 YA39 17/18 The registered person to ensure 30/11/06 that an organisational quality monitoring system is in place and implemented to measure success in achieving the homes aims, objectives and Statement of Purpose. Previous requirement not met 30/06/06. DS0000025927.V311577.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 YA34 Good Practice Recommendations The registered person to ensure that the staff files are organised in a way which provide information easily. DS0000025927.V311577.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000025927.V311577.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. 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