Inspection on 07/01/08 for Shrewsbury House

This inspection was carried out on 7th January 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shrewsbury House 09/01/07

Shrewsbury House 12/01/06

Shrewsbury House 23/06/05

Shrewsbury House 25/01/05

Shrewsbury House 10/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Shrewsbury House Shrewsbury House Battlebridge Lane Merstham Surrey RH1 3LT Lead Inspector Lisa Johnson Unannounced Inspection 7th January 2008 10:20 Shrewsbury House DS0000013789.V357456.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 Shrewsbury House DS0000013789.V357456.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. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shrewsbury House Address Shrewsbury House Battlebridge Lane Merstham Surrey RH1 3LT 01737 215135 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) Ashcroft Care Services Ltd Alan Joseph Bitsios Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18-65 YEARS 9th January 2007 Date of last inspection Brief Description of the Service: Shrewsbury House is a five bed roomed detached residence located in Merstham village. Three bedrooms are situated on the ground floor within close proximity to bathroom and toilet facilities. Communal areas on the ground floor include a spacious television room, a well-equipped kitchen and combined dining area. Separate utility facilities are situated in the conservatory. Upstairs there are a further two bedrooms, a second bathroom with separate shower and an office. Accommodation is domestic in scale and character. Local shops and community facilities are within walking distance of the home. Redhill town is accessible by public transport and provides a larger shopping centre and leisure amenities. The weekly fee ranges from £ 982- £1,734. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The site visit was unannounced and took place over six hours commencing at 10.20am and finishing at 4.30pm Mrs. L Johnson Regulation Inspector carried out this visit. The inspector spoke to three people who live in the service to gain their views and we spoke with two members of staff. Information was provided by the manager in the Annual Quality Assurance Questionnaire (AQAA) before this visit, which is reflected in this report. A full tour of the premises took place. Care plans, risk assessments, medication administration records staff personnel files, training records and policies and procedures were seen during this visit. The inspector would like to thank the staff and people living in the service for their time, assistance and hospitality during this inspection. The quality rating for this service is 2 star. This means that people who use this service experience good quality outcomes. What the service does well: The home provides a welcoming and friendly atmosphere. During this visit staff were seen to be respectful, caring and attentive to the needs of people living in the home. People spoken with during this visit said that were happy living there. One person said, “It’s a good house”. The home has formulated some documents in picture formats such as the service user guide and the complaints procedure. Management has been working with people to support them to raise issues and concerns. One person spoken with said, “I would speak to my key worker if I had any problems and she is nice”. People are supported to attend a range of leisure activities in the community, which meets their preference such as going to the cinema, attending college and participating in gardening clubs. One person said, “ I like visiting the library and another person said, “ I like to go out shopping” to buy things for his aviary, which he takes, care of. The AQAA states that the home intends to further promote equality and diversity and all staff are to receive training, to increase their knowledge and awareness of these issues. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 6 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 Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 8 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 Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective people moving into the service have the information they need to make an informed choice about the suitability of the home as a place to live. . The home will need to demonstrate that re- admission assessments are completed prior to any person moving into the home. However this has not been tested out, as there have been no new admissions since the last visit. EVIDENCE: The home provides a statement of purpose and service user guide, which are produced in a format to allow them to be read by service users. The service user guide describes the services that the home is able to offer, although it is advised that it reflects the current management arrangements in the home to ensure that up to date information is provided. Since our last visit there have been no new admissions in the home. People currently living in the home have resided there for a number of years therefore there were no assessments to view. The company has an admission procedure in place and information provided with the AQAA indicates that a preadmission assessment would take place involving gaining information from all stakeholders such as previous placement, relatives, care managers and any specialist services. The company has a central team who would support the Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 10 manager in making decisions about the suitability of the person. The home currently has one vacancy and it was recommended that copies of any assessments conducted for any future referrals are maintained in individuals file as good practice Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People using the service experience adequate in this area. This judgement has been made using available evidence including a visit to this service. The individual care plan is not sufficiently robust to enable care staff to understand the person’s current and changing care needs. Further improvement is needed to ensure that people are supported to make decisions about their daily lives. Risk assessments need strengthening to minimise any identified risks ensuring the safety and wellbeing of people living in the home. EVIDENCE: During this visit three care plans were sampled. Care plans were based on assessments of needs. Information viewed demonstrated that care review meetings are held six monthly with each person, their key worker and other professionals. Two out of three care plans need reviewing and updating ensuring that the current and identified changes in need are being met. Further improvement was identified in ensuring that people living in the service and/or their relatives sign their care plan to confirm their agreement as this was only evidenced for one person. Staff training has commenced in person centred planning and the manager stated that these new plans were due to be implemented shortly. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 12 During this visit the inspector spoke to two members of staff who act as key workers who had a good knowledge and awareness of the individual needs of people they support and are involved in care review meetings. The service has developed some documents in service user-friendly formats. The AQAA states that the home intends to further promote equality and diversity and all staff are to receive training, to increase their knowledge and awareness of these issues. The service conducts annual surveys with people living in the service. One person spoken with said that he attends his care review meetings. Staff also consult with families and other professionals to support decision-making. Discussion with the manager took place in respect of peoples finances and the support that people require. The manager plans to look at this matter to consider ways of supporting people to use their bankcards to increase their independence. Risk assessments were viewed for three people, which included for example support for risk of aggression and using transport. Although It was observed that one person had a risk plan and guidelines in place for the use physical intervention, which did not record when this was to be updated. During discussion with the interim manager it was felt that that this was in need of review as this is no longer required. It was also observed that another person uses electrical appliances such as the kettle and toaster, which was not supported by risk plans. Therefore it was recommended that this matter be addressed ensuring the persons welfare and safety. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 13 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, 15, 16 &17 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the service are supported to access a range of appropriate activities and they are supported to participate in the local community. People living in the home maintain links with their families and friends, their rights and responsibilities are respected and they are provided varied and wellbalanced meals. EVIDENCE: People have a weekly activities programme, which is based on individual preferences, likes and dislikes. Including attendance at college, reflexology, art therapy, gardening club, arts and crafts and music. Social events include going bowling, visiting the cinema, shopping trips visiting the pub and eating out at restaurants. The home has identified that it wishes to improve in exploring more varied activities and for people to participate in food shopping. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 14 One Person spoken with said, “ I like visiting cafes and shopping “. person said, “ I like visiting the library”. Another The home has access to two vehicles and some individuals chose also to use public transport. One person said that he went on a short break to Brighton but would like to go on a longer break this year”. Another person went away on holiday to Ireland. The service user guide states that the religious needs of people are supported. Some people have families with whom they maintain contact. One person has an advocate and one person regularly visits friends. A phone is available for people to maintain contact. People are able to meet their families and friends in private. People are supported to undertake domestic activities. One person spoken said, “I help with cleaning my room, doing my washing and help with cooking”. People living in the service are registered on the electoral role and are supported to make choices in their daily lives. One person has an aviary, which he likes to take care of and has tea-making facilities in his room. Another person said, “I was able to choose the wallpaper for my bedroom”. During this visit people were observed to have unrestricted access throughout the home. Good interaction was observed between people living in the home and staff who were sitting and eating lunch together. Menus are planned on a weekly basis with the involvement of people and are based on individual’s preferences. This was confirmed by one person who said, “I can choose the meals that I like”. Menus sampled during this visit were varied and well balanced. People spoken with during this visit said that were happy with the meals provided. The main meal is served in the evening and during this visit service users were offered with a range of sandwiches of their choosing. Fresh fruit was available for people to help themselves to. Meat is purchased from a local butcher. Snacks and drinks are available at all times evidenced by one person who was making himself a cup of tea Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 19 & 20 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The individual care plan needs strengthening to ensure that staff understand the personal support and preferences of people. People’s physical and health needs are met and they are protected by the homes medication administration procedures. EVIDENCE: Staff spoken with during this visit were observed to have a good understanding of the preferences, likes and dislikes of people living in the home. During this visit one person was observed to have a lie in which was respected by staff. One person said, “ Privacy is important to me and staff let me spend time on my own”. Two people also confirmed that staff knocks on their doors before entering. . We were informed that any new staff would shadow an experienced member of staff and that preferences of preferred gender of staff are accommodated and that routines of the home are flexible. However the home will benefit with the introduction of person centred plans, as details of peoples preferences are not recorded in the current care plan. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 16 Three care plans were sampled which indicated that people have access to a range of health care specialists including General Practitioner, chiropodist, dentist, dietician optician and behaviour specialists. Records were maintained of all health care appointments and consultations. Guidelines for supporting people were in place and monitoring charts were observed for example sleep pattern and behaviour monitoring, although improvement is needed ensuring that care plans reflect the current needs of people (see also standard 6) Since the last visit the company has reviewed and updated their medication administration procedure. Training has been reviewed with the manager having attended an assessor’s course who will be carrying out up-to-date assessments with staff. A list was maintained for all staff that are trained and authorized to administer medication. The medication cupboard was examined and medication was stored appropriately. Records for all medication received and disposed of were in place and the home conducts a weekly audit. The home uses a Monitored Dosage System (MDS). The inspector was informed that the pharmacist visits carry out medication audit. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that there is an accessible complaints procedure in place. Improvement is needed to ensure that all staff receive updated training in safeguarding vulnerable adults from abuse ensuring people using the service are safeguarded. EVIDENCE: The home has a complaints procedure in place which is also available in the service user guide and is formulated in pictorial format ensuring that it accessible to people living in the home. Since our previous visit the Commission has not received any complaints and no complaints have been received by the home. During discussion with the interim manager she stated that she has been consulting with people and supporting them as to how to make complaints which has also assisted with by the registered provider. Two people spoken with during this visit told us that would speak to their Key worker, the manager or others at the company’s head office. One person said that “Staff listen” if he has any worries or concerns. Another person said, “I like my key worker very much “. The local authority safeguarding adults from abuse procedures were present and the company has their own procedures including whistleblowing in place. A procedure was also seen on display in the office. Staff spoken with during this visit were aware of their responsibilities and the action that the they would Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 18 take if they ever witness or are made aware of any incident where the safety or protection of a vulnerable person is compromised. The interim manager has attended the local authority multi agency safeguarding adults from abuse training and staff spoken with and records available indicated that care staff receive training although it was observed that some staff require unto date formal training. One person had not received formal training for three years and another person had not received training for two years. Therefore it was required that this matter is addressed ensuring that people living in the service are safeguarded from harm and abuse. The financial records were examined for three people. Monies maintained on behalf of people checked and the balance was correct. Reasons for expenditure were documented and receipts were maintained. There was evidence that records are maintained of monies checked at the staff handovers. Since the previous visit the Commission has been made aware of one referral made following local authority multi-agency safeguarding vulnerable adults from abuse procedures. This lead to the organisation carrying out an internal investigation. This investigation has been completed which has resulted in the registered manager recently leaving the service. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 19 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): 25, 25 & 30 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home have a comfortable, clean and safe environment to live in although they would benefit further from redecoration and refurbishment of the premises. EVIDENCE: The home is located near to village shops and is accessible via transport to Redhill and Reigate town centres. There is a conservatory to the rear of the house, which leads to an accessible large well-maintained garden. There is a kitchen/diner; a lounge and separate quiet room is which contained a range of reading materials. The manager stated that a new programme of home improvement has begun which has included tidying the garden, repairs to the pathways and reorganisation of the office. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 20 Some areas of the house were identified that would benefit from further redecoration and refurbishment including paintwork throughout the communal areas. The furniture in the sitting room was seen to be worn and in need of replacement and the curtains were hanging off the rails. These matters were bought to the attention of the manager during this visit. Bedrooms are located over two floors and bedrooms viewed were comfortable and reflected peoples individuals preferences and were personalised. The home was cleaned to a good standard and was hygienic and cleaning schedules are in place. The home has an infection control procedure in place and separate washing facilities are in provided. Arrangements are in place for staff to attend infection control training. Since the previous visit the previous visit the home has completed the “safer food Better Business pack and installed new food hygiene monitoring. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 21 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 & 35 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty adequate to meet the needs of people living in the service. People living in the home are in safe hands of staff that are trained and competent to do their jobs. People living in the service are protected by the homes recruitment policies and practices. EVIDENCE: During this visit there were three members of staff on duty, which reflected the information recorded on the duty rota. During the day there are three members of staff and at nighttime people are supported by a waking member of staff and a sleep-in person. The home has an equal opportunities policy in place. The staff team are of mixed gender and ethnicity. There has been no new staff employed by the home in the last year. Information supplied in the AQAA stated that people living in the home would have the opportunity to meet any possible candidates to assess their suitability. The home has a key worker system in place and staff spoken to during this visit were about aware their roles and responsibilities. Information supplied with the AQAAA indicates that fifty percent of staff hold National Vocational Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 22 Qualifications (Level 2) or above. The company employs a training manager and a training schedule was maintained in the home which records when staff are due for their next training update. Evidence gathered indicated that staff receive, mandatory training in health and safety, first aid, food hygiene and moving and handling. Evidence was provided to the inspector by the training manager of planned future training. Although improvement was needed in ensuring that staff receive updated training in safeguarding adults from abuse. (See standard 23). At the time of this visit one member of staff was working on bank and mainly works at another home where this persons file is maintained. This member of staffs personal file was provided to the inspector but did not contain records to verify what training they had completed. We were informed that these records were kept at the home where this person is based but this information wasnot able to be obtained during this visit. Other evidence gathered confirmed that staff receive training in challenging behaviour autism, challenging behaviour and non- violent crisis intervention, which meets the needs of people living in the home. Training has commenced for staff in person centred planning, equality and diversity and for managers to attend mental health capacity Act awareness training. Although there have been no new staff employed since the previous visit information was provided to the inspector that an induction programme is in place based on the Skills for Care common induction standards. Three members of staff personnel files were examined which contained the required information including Criminal Records Bureau checks (CRBs). The company also carries out POVA first checks. The General Social Care Code of conduct is bought to the attention of staff and was also seen on display in the office. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 23 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 &42 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. The service is able to demonstrate that people living in the home benefit from a home, which is well run and in their best interest although consideration should be given to appointing a permanent manager. The health safety and welfare of people is protected. EVIDENCE: A manager’s vacancy has arisen and the home is currently being managed by another registered manager who divides her time between this home and another home owned by the same provider. The manager holds a National Vocational Qualification (Level 4) in care and is working towards the Registered Managers Award. There is also currently no deputy manager in place although the company is addressing this matter. Staff spoken with said that they felt supported by the interim manager, that she was accessible and approachable. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 24 Since the interim manager has commenced she is in the process of reintroducing staff meetings. The manager demonstrated clearly thorough the AQAA and during discussion that she has identified areas for improvement which she has commenced taking action on. It is recommended that the provider now consider addressing the permanent management arrangements of the home to provide consistency to meeting the needs of people living in the home and to support staff. Monthly quality visits are conducted and these reports were available for viewing and were detailed and comprehensive. The Company conducts carries out consultation with service users relatives/representatives and other stakeholders, which includes carrying out quality assurance feedback surveys. It is recommended that the outcomes of surveys be maintained in the home for viewing. There are a number of policies and procedures that need reviewing, as these are out of date. Information provided by the company, the AQAA and during discussion with the manager indicates that this work is in process. The company is also planning to introduce a staff handbook, which will highlight procedures for good practice. There is a health and safety policy in place. Water temperature testing is regularly checked and recorded. Evidence gathered indicated that regular servicing and maintenance of equipment is conducted including gas, electrical and legionella testing. The fire book was examined which confirmed that regular alarm checks and fire drills are conducted and new fire risk assessments have been put in place. All substances hazardous to health were stored and locked away appropriately with appropriate data maintained. A requirement was made at the previous inspection risk assessment is completed in respect of the need to install radiator covers. Information gathered from risk assessments viewed confirmed that this had been conducted. Although it is recommended that the service consult with the Environmental Health office to confirm that the services risk assessment for radiators not being covered meets legislation. Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 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 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 3 X X 3 X Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 26 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 YA23 Regulation 13(6) Requirement The registered person must ensure that staff receive updated training in safeguarding adults from abuse. Timescale for action 09/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 2 3 Refer to Standard YA9 YA37 YA39 YA42 Good Practice Recommendations It is recommended that a risk assessment is completed for the person who uses electrical appliances The provider should give consideration to the permanent management arrangements of the home. It is recommended that the outcomes of the quality assurance surveys be made available for viewing It is recommended that the manager consults with the Environmental Health department to confirm that the services risk assessment for the uncovered radiators meets the organisations legislation Shrewsbury House DS0000013789.V357456.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 6NT 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 Shrewsbury House DS0000013789.V357456.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. 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