Inspection on 01/05/08 for South Road (38)

This inspection was carried out on 1st May 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

South Road (38) 02/05/07

South Road (38) 14/11/05

South Road (38) 26/07/05

South Road (38) 15/06/05

South Road (38) 06/01/05

South Road (38) 30/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 South Road (38) 38 South Road Bishops Stortford Hertfordshire CM23 3JJ Lead Inspector Jane Greaves Unannounced Inspection 1st May 2008 08:45 South Road (38) DS0000019529.V363793.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 South Road (38) DS0000019529.V363793.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. South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Road (38) Address 38 South Road Bishops Stortford Hertfordshire CM23 3JJ 01279 461 131 01279 466 332 clive.kidd@hft.org.uk www.hft.org.uk Home Farm Trust 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) Mr Clive William Kidd Care Home 10 Category(ies) of Learning disability (10) registration, with number of places South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd May 2007 Brief Description of the Service: 38 South Road is a large house in a residential street on the outskirts of Bishops Stortford. It provides accommodation for ten people with a mild to moderate Learning Disability. All people have their own rooms, which reflect their individual personalities, and all make full use of all the local community has to offer. Emphasis is given to active, positive quality lifestyles at the limit of each service users ability and independence. The home is owned by the Home Farm Trust a voluntary organisation. A copy of the previous inspection report published by the Commission for Social Care Inspection is available at the home on request. The current fees for the residents, who are all sponsored by a local authority, range from £720 to £850 per week according to need. South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced site visit took place over 5 1/2 hours on 1st May 2008 and a second visit of 1 1/2 hours on 6th May 2008. We looked at how the home meets the needs of the people living at 38, South Road. A physical tour of the premises was undertaken and a selection of care records, staff records, medication records and other documentation were assessed. We spoke to some people living at the home, some staff members and the management team during the course of the visits and some family members by telephone subsequent to the site visit. Prior to this visit surveys were sent to the home for residents, relatives and staff members to express their views about the service provided at 38, South Road, comments from these surveys have been included within this report. What the service does well: Family members spoken with subsequent to the inspection site visit had very positive things to say about the care and support provided at the home. Examples of such feedback is as follows: “In the short time that my relative has lived at 38 South Road they have settled in very well and loves living there. We think that the manager and his staff work hard to make newcomers feel very welcome and ‘at home’”. “I am very pleased with the progress X has made since moving into 38 South Road. X has become a more settled and secure individual and is very happy with life in this house. This cannot be underrated.” “We think very highly of South Road and are extremely grateful that X is living there. It is always possible to find small faults but that doesn’t override the general feeling of satisfaction with the home” 90 of the staff team has achieved a minimum of NVQ level 2 qualification in care. This means that the people living at the home can be confident that the staff team has the collective skills to keep them safe and healthy. South Road (38) DS0000019529.V363793.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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. South Road (38) DS0000019529.V363793.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 South Road (38) DS0000019529.V363793.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 can expect to have a thorough pre admission assessment to ensure that the home can meet their needs. EVIDENCE: People were encouraged to have various visits to the home on a trial basis before moving so that they could see the home, meet the people that already lived there and get information. The registered manager reported that a full report was made about each visit to feed into the overall assessment of needs however there was no documentary evidence available in file of these pre admission trial visits. We looked at the records of two people admitted to the home since the previous inspection visit. Pre-admission assessments had been undertaken and a care plan had been put in place. One relative reported that they had been fully involved in the pre-admission planning process, and stated that the staff had been “very helpful and asked me what I thought X needed before moving into the home”. South Road (38) DS0000019529.V363793.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 can expect to have a plan of care that reflects their assessed needs. People are involved in decisions about their lives and play an active role in deciding what support they get and how that support is given. EVIDENCE: The care plans we looked at as part of this inspection site visit were mainly current and orderly. Care plans included specialist requirements such as OT, Physiotherapy and speech therapy. Restrictions of choice were recorded with clear reasons why the restrictions had been put in place. From activity observed during the day and from discussion with staff and people living at the home, information on the documents provided a rounded ‘pen picture’ of individuals’ needs. Risk assessments were detailed and current and subject to constant review. Daily records confirmed that identified ‘life’ needs are being met and guidelines are being followed. Records of social and leisure activity sheets provided an at a glance summary of what activities people attend. South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 10 Staff demonstrated good knowledge of all aspects of peoples’ lives and how support was needed. The service uses various means of offering choice. The people living at the service had been actively involved in making charts for the dining room wall with pictures depicting choices for holiday venues such as Spain and Devon, favourite meals, summer activity ideas such as visiting an animal park, bowling, visiting stately home and the seaside. Each person living at 38, South Road had an agreed individual budget arranged between themselves and their nominated key worker. It was noted that some people had signed these budgets to show their agreement and some had not. The management team reported that if people did not have the capacity to understand their own finances they were not expected to sign to demonstrate agreement however in those instances their key worker signed the budgets on behalf of individuals. Budgets were done to support people to gain financial awareness and learn to understand the value of money and to help them save towards annual holidays for example. Evidence was included in the care plans to show that risk was assessed during the admission process and in discussion with the individual, their families and representatives and relevant specialists. Appropriate risk management strategies were agreed, recorded in the individual plan, and reviewed. Action was taken to minimize identified risks and hazards, and people were given training about their personal safety, to avoid limiting individuals’ preferred activity or choice. South Road (38) DS0000019529.V363793.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, 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 can expect to receive a balanced and varied diet and choices of leisure activity to meet their individual needs. EVIDENCE: People living at 38, South Road were supported and encouraged to enjoy a full and stimulating lifestyle with a variety of options to choose from. Staff members reported, and daily records confirmed, that people attended cinemas, theatre, bowling alleys, shops, restaurants, colleges, various clubs, and many other activities. One person said to us at this visit “I like to go to the bowling alley and playing pool and watching football with friends”. Individuals had opportunities to voice their wishes regarding social events at house meetings. The staff demonstrated awareness of the social needs of the people living at the home and encouraged and supported them to access a full range of activities both inside and outside the home. South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 12 Family members said they are always encouraged to visit the home. They can visit with their relative in private in their own room or in the communal areas of the home with other residents’ agreement. One relative said, “The staff are really nice, I often visit and I am always made welcome, it feels like home”. The service considered individuals’ changing needs and choices when planning the routines of daily living and arranging activities. The views of the people living at the home, and their families were taken into account. Household tasks were shared amongst the people living at the home with each person having their own areas of responsibility clearly detailed within their support plans. This was discussed at residents meetings; this was confirmed in the minutes of previous meetings. Individuals were encouraged to make their own choices regarding what food they ate on a daily basis, and the people living there confirmed this on the day. One person said to us, “I cook once a week for everyone, staff help me”. The kitchen was clean and fresh however the freezer was in need of defrosting. The record of meals eaten by individuals was incomplete. Staff reported that people living at the home are responsible for completing this record but another method needs to be found in order to have an accurate record of the meals provided. South Road (38) DS0000019529.V363793.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 can expect to receive well-managed personal and healthcare support that is tailored to meet their changing needs. EVIDENCE: People’s health care needs were recorded in individual support plans and they were helped by staff to take decisions regarding their own health care needs. The support plans were being developed to provide more comprehensive and concise healthcare information for staff to follow. People living at 38, South Road were not involved with recruitment of new support workers and therefore did not have a choice of the people that worked closely with them. Evidence was included within the support plans to confirm that the community nurse, Occupational Therapist and physiotherapist were involved in the care of some of the people living in the home. South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 14 People living at 38 South Road required minimal support with their personal care. Support plans indicated, and the people living at the home and management team confirmed, that prompting was required for people to varying degrees. Relatives’ surveys included the comment “Sometimes supervision of teeth cleaning, nail cutting and shaving etc. can be a little scanty”. On the day of this visit support staff members were observed gently prompting individuals to attend to personal hygiene needs. The level of detail and standard of daily recording varied greatly, some gave good detail of how people spent their days whilst others provided no evidence of choices being offered to people or made by them. Policies and procedures were in place for the safe administration of medication and all medication was kept locked in secure facilities. The records for the administration, receipt, and disposal of medication had occasional gaps in recording meaning that it was not always possible to be sure if medication had been given. The staff reported that those people are responsible for administering medication had received the required training; training records confirmed that 8 of the 10 staff members have received training since November 2006. South Road (38) DS0000019529.V363793.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. People living at 38 South Road can expect to have any concerns taken seriously. EVIDENCE: The home had a well-designed pictorial complaint procedure. Staff reported that in 9 out of 10 instances the people living at the home would ask for staff support to fill the complaints form in. People who live in the home explained to us in detail how they could make a complaint and who to make a complaint to. The records of complaints indicated that people living at 38 South Road were confident to raise any concerns they had, either about behaviours of housemates of issues with their care and support. Protection of Vulnerable Adults (PoVA) training was included within the service’s induction programme and a recent recruit who had recently completed this training confirmed this. Training records seen subsequent to the inspection site visit confirmed that 8 of the 10 staff members had attended (PoVA) since February 2006. It was noted there was a copy of Hertfordshire Adult Protection Procedures in the office for staff to refer to. There was a Protection of Vulnerable Adults investigation at 38, South Road ongoing at the point of this visit. The management team had followed the home’s policies and procedures to promote the safety and welfare of the people living there. South Road (38) DS0000019529.V363793.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 adequate. This judgement has been made using available evidence including a visit to this service. People can expect the home to meet their basic needs, however the environment is not always homely, clean and fresh. EVIDENCE: A physical tour of the building was undertaken as part of this inspection site visit. The communal lounge did not have sufficient seating available should all people living at the home wish to use the room at the same time. The manager responded that it was unlikely that all people living at the home would be wishing to use the lounge at the same time however there was no other space available for people to receive visitors apart from their personal rooms. Surveys returned to the commission as part of this inspection process reported that there were insufficient dining chairs and that many were broken. On the day of this visit there were 14 chairs and none were broken. South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 17 People living at 38, South Road reported they had been involved with choosing colour schemes when redecoration took place and staff reported that the pictures hanging on the lounge wall had been chosen by residents, however the communal areas of the home did not reflect the varied personalities of the people living in the house. The communal areas of the home were mainly tidy with the exception of the fridge doors, a vacuum cleaner and a filing cabinet that were being stored on the upstairs landing and a large non functioning fridge positioned by the back door. Many parts of the home did not appear clean and fresh at this visit; it was acknowledged that the people living at the home do the cleaning with very little assistance or supervision from the support staff. The lounge had some large cobwebs, was dusty and the curtain rails were falling down. The downstairs bathroom appeared tired with peeling paint on the windowsill, stained flooring and a damaged bath side. It was reported that none of the showers in the house worked properly. The management team acknowledged this was a problem experienced previously due to the high amount of lime scale in the area. Carpeting in hallways was very dusty and had debris at the edges where little attention had been paid to cleaning. Staff reported that a deep clean takes place at the home twice a year but the spring clean was overdue. Three people invited us to view their personal rooms. In one we saw a stained mattress, stained carpeting and the curtain was falling down. Comments received from family members included “X is not very tidy, I think they could help them keep their room tidier”. People spoken with were happy they could personalise their own space and did not recognise that the rooms were untidy or needed further cleaning. The home did not have an on-going maintenance programme; essential maintenance was only done when a problem had already arisen. Some of the fixtures and fittings were tired and in need of replacing and some of the décor required upgrading. South Road (38) DS0000019529.V363793.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, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can feel confident that they will be looked after by safely recruited and well trained staff. EVIDENCE: Recruitment records were seen for a support worker recruited to work at the home since the previous visit, this file confirmed that all necessary checks were completed to ensure the right people were employed to support people safely. Discussion with staff and records confirmed that no person started to support people living at the home until a satisfactory Criminal Records Bureau enhanced disclosure and satisfactory references had been received. The people living at the home were not included in the process for recruiting new staff, this meant they did not have a say in who provided their support. Training records viewed subsequent to the inspection site visit confirmed that the support staff team received the basic core training necessary to promote the health and welfare of the people living at the home. This training included South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 19 a structured induction, food hygiene, and protection of vulnerable adults, health and safety, 1st aid, and safe administration of medicines. Staff survey responses indicated they were not provided with some areas of training specific to the needs of the people living in the home and that there were gaps in their knowledge to assist them in advising people about personal and intimate relationships. Staff surveys included comments such as “I personally feel more training could be given regards to the different disabilities. Background knowledge would be a big help” and “I feel that in depth challenging behaviour training was vital, I wasn’t given this for 6 months and then I don’t feel it was sufficient. All over, training was very helpful” and “More experience and training would be helpful eg sexual orientation & communication needs”. Training records showed that 2 people had received Mental Capacity Act training and the service does not routinely provide infection control training. Training records showed that 9 of the 10 staff members had achieved a minimum of NVQ level 2, this exceeds the recommended ratio and should be commended. The service had a small stable staff team but had recently lost some long serving staff members; agency staff members were covering vacancies whilst a recruitment drive was undertaken. It was reported that the high usage of agency staff resulted in very little time to do routine chores such as type up meeting minutes and completing documentation. Staff also reported having less time available to spend 1:1 time with individuals. The registered manager had been managing the service remotely from other Home Farm Trust premises for approximately 8 weeks; this has had a negative effect on staff supervision and morale. The manager was able to demonstrate that staff supervision sessions had taken place in January and February of this year and staff surveys and staff spoken to confirmed this was the case. Information provided subsequent to this visit showed detail of supervisions planned for March and April however there was no evidence that these had taken place and there was no evidence of any further dates planned. Where the service is undergoing a period of instability with high agency usage and senior support staff are managing the service on a day to day basis a robust supervision programme would be expected. South Road (38) DS0000019529.V363793.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, 38, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home can be confident that their views and opinions matter. The staff team currently lacks effective leadership and support. EVIDENCE: The registered manager had the necessary experience to run the home however had been managing this service remotely from another Home Farm Trust site for the two months prior to this visit. The staff team and the manager reported that there had been regular contact with the team during this period however staff supervisions had not taken place since February, staff morale was reported to be very low and the lack of leadership was evident in record keeping visit. South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 21 Record keeping was generally up to date although some gaps and inconsistencies were noted in recording and entries were not always clear. Examples of areas of shortfall in record keeping included gaps in medication records, lack of documentary evidence of trial visits taking place before people move into the home, incomplete records of food intake by people living at the home and one of three care plans viewed did not have a photo of the person. Another where a lack of management presence was noted to directly affect the lives of the people living at the service was the environment. Staff were not supporting residents to keep the communal areas of the home clean and fresh and people were not given sufficient encouragement to keep their personal rooms clean and tidy. Staff surveys included comments such as “We were having regular supervisions but haven’t been able to for 6 weeks now due to manager working at a different site”. It was reported that the service had received phone calls from some family members concerned about the manager not being on site. An assistant service manager from within the Home Farm Trust organisation attended the home once a week to provide support for the senior support worker. The registered manager had achieved NVQ level 3. He reported the completion of NVQ level 4 and that he was awaiting receipt of the certificate to confirm this achievement. Evidence was submitted subsequent to the inspection site visit to confirm he had attended refresher training in the last year in food hygiene, health and safety, 1st aid and mental capacity act training in order to update his skills and knowledge. The organisation operated a Quality Assurance system undertaken by people from outside this service. As part of this process time was spent with individuals that use the service to assess their daily living experiences such as eating meals and what they do with their day. The previous inspection report identified that the manager was developing a questionnaire in picture format so that the views of the people living at 38 South Road could be gathered and assessed independent from the organisation’s Quality Assessment process. Subsequent to this site visit a summary of the results of this survey were forwarded to us to consider within this report. The manager acknowledged the surveys needed further development to ensure that all people living at the home were able to take part in the process. The service has a strong commitment to the health and safety of both the people living in the home and the staff team. The support staff team receives Health and safety training, and the service has a range of policies and South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 22 procedures relating to health and safety practices. Individual resident risk assessment and premises assessments are in place. Evidence was available to indicate that every effort was made to ensure the health, welfare and safety of individuals who live in the home, and support workers. South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 23 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 2 3 X X 3 X South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 24 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 YA17 Regulation Schedule 4 (13) Requirement Timescale for action 31/07/08 2 YA20 13(2) 3 YA24 16(2)k 23(2)d Records of the food provided for the people living at the home need to be completed in sufficient detail to show that the diet is satisfactory in relation to nutrition and choice. Records of medication given to 30/06/08 people living at the home needs to be accurate to ensure the right amounts are given to people at the right times. The home should be clean and 31/07/08 fresh to provide a pleasant environment for people to live in. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 South Road (38) DS0000019529.V363793.R01.S.doc Version 5.2 Page 26 - 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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