Inspection on 06/09/06 for St Alban`s Cottage

This inspection was carried out on 6th September 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Alban`s Cottage 23/08/07

St Alban`s Cottage 02/02/06

St Alban`s Cottage 10/05/05

St Alban`s Cottage 29/09/04

St Alban`s Cottage 04/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 St Alban`s Cottage 2a St Alban`s Close Harehills Leeds West Yorkshire LS9 6LE Lead Inspector Stevie Allerton Key Unannounced Inspection 6th September 2006 10:45 St Alban`s Cottage DS0000001496.V302744.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 St Alban`s Cottage DS0000001496.V302744.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. St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Alban`s Cottage Address 2a St Alban`s Close Harehills Leeds West Yorkshire LS9 6LE 0113 240 1837 0113 2401837 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) None United Response Miss Sally Casterton Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2006 Brief Description of the Service: St. Albans Cottage is a four-bedroomed bungalow, purpose built to accommodate service users with multiple disabilities, who do not require nursing care. The bungalow is situated at the head of a cul de sac in a quiet residential area just off the York Road in East Leeds, with nothing to distinguish it from the outside as a care home. The area is a short distance from local shopping centres, sports and leisure facilities, with good access via public transport from Leeds. The home accommodates four young adults with learning disabilities and some physical disabilities, most of whom are wheelchair users. The property is managed by a housing association but the care service is provided by United Response, a national charity specialising in the field of learning disabilities. There is a Manager in post, who has yet to apply for registration, and there is close line management supervision from the area office in York. Care fees are currently £1,313.67 per week. St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out without prior notification and was conducted by one inspector over the course of one day, starting at 10.45am and finishing at 6.00pm. The Manager, Jane Hughes, was not on duty until lunchtime. One of the Senior Support Workers, Sarah Fraser, assisted the inspector initially and was joined later by the Manager. Other staff on duty were also seen during the course of the day. The inspector would like to thank everyone who took the time to talk and express their views. Survey forms were sent out to a selection of health and social care professionals and one was returned. New easy-read survey forms were also sent to each person living at the home. All were completed and returned prior to the visit. Before the visit, accumulated information about the home was reviewed. This included looking at any notified incidents or accidents and other information passed to CSCI since the last inspection, including reports from other agencies, such as the Fire Officer. This information was used to plan this inspection visit. The inspector case tracked two service users. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, the inspector assessed all twenty-one key standards from the Care Homes for Younger Adults National Minimum Standards, plus other standards relevant to the visit. The inspector spent time with identified service users and spoke to relevant members of the staff team who provide support to them. Documentation relating to these service users was looked at. Where possible, contact was also made with external professionals, to obtain their opinions about the quality of services provided at the home. St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 6 What the service does well: 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. St Alban`s Cottage DS0000001496.V302744.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 St Alban`s Cottage DS0000001496.V302744.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&5 Quality in this area is adequate. This judgement has been made using available evidence, including a visit to the home. The home is careful in its assessment process, to ensure that the service will be right for each individual; this also takes into account the needs of the present service users. The admissions process is suited to the pace of the individual. The Manager needs to be clearer about who provides information, by way of a contract, to the service user and their family and at what stage this should be provided to them. EVIDENCE: The newest service user was case tracked, looking at the information that the home gathered prior to admission; this was thorough, information obtained from a wide range of professionals involved in the person’s care. Information from the prior placement was being used to formulate an initial support plan. There was no evidence of a copy of the service user guide or contract having been given out yet, although the person had been in residence for a few weeks. The Manager was unsure whose responsibility it was to formulate the contract, whether this came from the area office in York or not, but would chase it up. St Alban`s Cottage DS0000001496.V302744.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this area is good. This judgement has been made using available evidence, including a visit to the home. Service users are encouraged to contribute to their own support plans; the use of the first person (“I would like…” or “I prefer it if you…”) is an empowering tool that puts the service user at the centre of everything staff do. Staff have no control over how the funding package is arranged for each person, but are proactive in trying to influence changes that would benefit the individual. EVIDENCE: Two service users who have a different range of needs were selected for case tracking, one being a recent admission and one having lived there for a few years and whose health is now deteriorating. Support plans are written in the first person and very detailed for staff to follow in the case of the long-standing resident. Risk assessments were in place. The support plans for the newest person are not fully in place yet, so the plans from his previous placements are being used and adapted as new things are discovered. The Manager said that they would wait until all of their own support plans had been completed, and replace the old ones all at once, St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 10 rather than run two systems. She acknowledged that the plans currently being worked from are basic and not written in a way that empowers. Support plans were seen to describe how each person indicates choice and this was confirmed when observing staff supporting them later in the day. The communication plan seen for one service user was excellent. The care fees are based on service users attending day care elsewhere and the home is not staffed to provide one to one time during the day, unless someone has an Individual Support Worker funded. The Manager has been proactive in getting service users assessed by Occupational Therapists, etc, to provide professional evidence that individuals would gain benefits from being allocated some one to one staff time, rather than attending adult day care services 5 days a week. Staff spoken to felt that immense benefits had been seen from giving people more individual time, either spent at home or going out for different activities. In the case of one service user, her health had been the chief factor in negotiating for more time at home. Two of the easy-read surveys returned by service users said that they had not been given a choice about whether they wanted to attend day care services 5 days a week, but felt they had plenty of choice within the home itself. Staff are very aware of equality & diversity issues with the people they support. Not only is training given in this area, but the way that support plans are written empower the individual to direct how they wish to be supported. A member of staff said that the easy-read surveys sent out by CSCI were good to use; she was able to go through them with each service user and point to the pictures/symbols to get their response. St Alban`s Cottage DS0000001496.V302744.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this area is good. This judgement has been made using available evidence, including a visit to the home. There are continued opportunities to take part in the ordinary activities of daily life. Leisure activities are varied and tailored to each person’s likes and interests. Social opportunities have been able to expand for some people as they cease to attend day care full-time. Other service users would benefit from a similar approach, subject to funding. Meals are adequate, but could be further improved with regard to variety and nutritional balance. EVIDENCE: One service user was at home on the day of inspection and the other three were at day centre, two being seen on return during the afternoon. Activities being carried out with the staff concurred with the activity schedule within the support plans. One lady was going out for lunch with a carer, then to see a film in the afternoon, home again for tea. The written records of this person’s care reflected her involvement in all kinds of daily activities, such as gong shopping, being supported by staff to do household tasks and having friends round for tea. St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 12 The other service user who was case tracked enjoys going to the day centre two days each week, as he likes the social opportunities there. At home, he spends time doing things he likes, the staff gradually getting to know him and assessing what wider range of social and leisure activities he might like to do. He was seen in his bedroom, but was occupied with his music tapes and did not want to talk. Support staff assist service users with food preparation. This was seen in action, the person whose turn it was to be supported to make the evening meal, expressing his enjoyment at being fully involved in mixing the batter and putting the sausages in the roasting dish for “toad in the hole”. Staff were seen to be mindful of good hygiene practice, supporting the service user to wash his hands and put on an apron prior to handling the food. Menus were supplied prior to the inspection. They were discussed with the Manager, who was asked how close she felt they were getting to the recommended “5 a day” principle; she felt they weren’t really and, up until recently, menu choice had largely been led by a former service user who was very able to express his preferences, which weren’t always healthy ones. She said that the range of meals had improved, but felt they could still improve. There are some African support staff, who have introduced some of their traditional meals to the home. African and English recipe books are now in use, so that staff from whichever background can produce the meal as planned, despite such ambiguous names as “toad in the hole” and “shepherd’s pie”. St Alban`s Cottage DS0000001496.V302744.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this area is good. This judgement has been made using available evidence, including a visit to the home. The staff team support the service users in a way that promotes their dignity and privacy. Good attention is given to health care needs, and appropriate action taken as these needs change. Medication procedures and practice are sound. EVIDENCE: Two service users were case tracked, one of whom is experiencing a deterioration in health. Care and support records were looked at for this person, with regard to health and personal care issues. There was written evidence to show that appropriate advice and treatment had been sought from the GP and other health care professionals. A recent hospital admission had been necessary, the home staff supporting the person as much as possible whilst on the ward. Formerly attending adult day care service full time, this had subsequently been reduced to two days each week, as the service user had been finding it over-tiring. The service user was at home on the day of inspection and had been able to get up in a more leisurely fashion. St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 14 Other records showed that service users had input from Occupational Therapists and Physiotherapists, in order to make sure that wheelchairs continue to fit properly, for example, or to arrange for hydrotherapy sessions, as appropriate to the individual. In observing the morning and afternoon routines, personal support given by the staff was seen to promote the privacy and dignity of the individual. Medication procedures continue to follow good practice. The records were up to date and no anomalies noted. There was a good example in the medication file, showing staff the process of ordering repeat prescriptions. St Alban`s Cottage DS0000001496.V302744.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this area is good. This judgement has been made using available evidence, including a visit to the home. There are clear procedures in place, both for complaints management and for the protection of vulnerable adults. Staff have a good level of awareness of abuse issues, supported by training and written policies. Service users’ finances are well managed and the systems in place safeguard them and the staff managing their money. EVIDENCE: The provider organisation has demonstrated that it can investigate complaints made about the service, in an appropriate manner. Staff receive training in Abuse Awarenes during their induction training; this is also covered in Equality & Diversity training. Staff spoken to were knowledgeable about their responsibility to protect the people they support from abuse. Service user surveys all indicated that they knew who to tell if they were not happy or wanted to make a complaint. Service users’ finances are managed by the staff. Records and procedures relating to the management of finances were looked at. Systems are easy to follow and there is a clear audit trail for all income and expenditure. Contributions are made from the mobility component of individuals’ welfare benefits, towards the home’s wheelchair-accessible vehicle, used by all of the service users. Records are kept of these contributions. St Alban`s Cottage DS0000001496.V302744.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 29 & 30 Quality in this area is good. This judgement has been made using available evidence, including a visit to the home. The home is well-equipped and furnished in a comfortable and homely way. The addition of ceiling tracking to two more bedrooms will improve the level of personal support to those service users, both of whom are wheelchair users. Good standards of hygiene and cleanliness are achieved, the staff supporting the service users to take part in these tasks. EVIDENCE: The house was clean, tidy & well decorated throughout. All of the service users chose their preferred colours for their bedrooms, apart from the newest admission, whose room was decorated in a neutral colour when it became vacant. The problems with the shower room have now been resolved and it is fully functional again. A new shower trolley is on order, as is ceiling tracking for two more service users’ bedrooms. St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 17 In the hallway are communication boards, showing with pictures and symbols what is happening that day for each person. Service users do their laundry, supported by the staff; people were seen being supported to put their clean clothing away when they came in from day care. The support staff do the cleaning as well as cooking. All but two have their Food Hygiene certificate, the remaining two booked on to the next available course. There are written standards in place for the cleaning of all areas of the home; cleaning schedules link to these standards. Therefore staff have a routine for certain tasks to be done, either during the day or at night, and can check with the written standard how these should be carried out. St Alban`s Cottage DS0000001496.V302744.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this area is good. This judgement has been made using available evidence, including a visit to the home. Service users benefit from a well trained and supervised team of staff, who are committed to supporting service users in ways that respect them and empower them. There is a positive approach to training and staff are able to demonstrate a good level of knowledge about the people they support. There is a good rapport between service users and their support staff. The introduction of easy to use versions of staff appraisal forms, allows service users to have a real say in who they want supporting them. EVIDENCE: Staffing arrangements have altered slightly since the last inspection. The Manager is now supported by two Senior Support Workers, enabling some management responsibilities to be delegated and Support Workers to be appropriately supervised. There are two vacant support worker posts of 26 hrs each, currently being covered by agency workers. Another post has recently been filled, Criminal Record Bureau checks awaited before they start work. The home tries to get the same few workers from the agency, as it makes for better continuity for service users. The Manager is currently trying to get additional hours funded for a service user to remain at home more and receive one to one support. St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 19 New staff are subject to a period of probation, during which they are expected to be able to demonstrate set competencies before their employment becomes permanent. A recent document has been produced, using Change Picture Bank, for service users to be involved in the assessment of staff at the end of their probationary period. This asks simple questions about the tasks staff do, the support they give and their attitudes towards the service users. The Manager works 30 hours per week at St Albans and 7.5 hours at the house where a former service user now lives independently, with 24 hr support. Supervision takes place monthly, shared responsibility for this between the Manager and the two Seniors. Staff files were available for inspection, copies of application forms, references & CRB checks kept in the home. Those seen met with requirements. Staff said they were looking forward to being a full team again shortly, as it would enable them to do more with individual service users. The rota shows sufficient staff on duty to meet support needs within the house and a reasonable degree of individual support outside, but more was aspired to. Skills for Care Induction training is being done in-house, new staff working through their induction packs; however, the senior said that these induction standards were very generic and not specific enough to support the work in this service, so are being backed up by the home’s own structured checklist. This shows how staff gradually gain competence in supporting each of the four service users, in a variety of personal care and daily living tasks. Staff previously had to go to York to attend core training, but this is now being delivered in Leeds by another provider. Free Infection Control training has also been accessed locally. There was a student nurse on duty alongside the staff on the day of inspection; she had just come to the end of a 9 week placement from LMU and felt that it had been a good experience. She had been able to attend United Response’s Equality and Diversity training whilst on placement here. There is written guidance to staff regarding the role of the Keyworker at St. Albans. The Manager is currently developing a 2 day training course in Keyworking, which should be available to all UR staff eventually. National Vocational Qualification training is being carried out, provided by Yorkshire Business School. The Manager said that they had had an excellent level of support, the assessor coming to the home once a month to see candidates. Three more staff were starting NVQ later this month. St Alban`s Cottage DS0000001496.V302744.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41 & 42 Quality in this area is good. This judgement has been made using available evidence, including a visit to the home. The home is well run, with the service users at the centre of the home’s values. There is an excellent example of the staff team’s commitment to service user inclusion in all aspects of the running of their home, by the introduction of easy-read documents. This is going to create a large amount of work for staff, particularly in translating the service user’ support plans, but there is enthusiasm and commitment to what is seen as an important piece of work. The staff are supported by the organisation’s policies, procedures and administrative systems. Quarterly audit checks are carried out, ensuring that United Response’s standards are met. Record keeping is good, but the staff team need to be more aware of when they need to report incidents to CSCI. Steps need to be taken to get the Manager registered without any further delay. St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 21 EVIDENCE: The Manager has been in post for 12 months but has not yet applied for registration with CSCI. She advised that her application was about to be forwarded. The Manager needs to be clearer about the requirement to notify CSCI of particular events, i.e., a recent break-in, during which a night carer’s bag was taken. This took place 2 months ago but CSCI were not notified. A new protocol for night duty has been drawn up in response to this incident, and staff are to keep a personal alarm and the mobile phone on their person at all times. Next year’s service plan is being drawn up. A letter and questionnaire to relatives was seen, also user-friendly versions for service users; staff are also being consulted, pooling peoples’ ideas together for the development plan and looking for outcomes that can be measured in 12 months time. A sample of records were seen, including fire safety records, medication, finances, staff rotas, staff files, health & safety, menus and kitchen hygiene records. All records appeared to be accurate and up to date. Service users’ financial records have in-built checks and balances in order to protect their interests. There are plans by the staff to translate support plans, staff rotas and other relevant information over the next 12 months, into Change Picture Bank documents, so that service users will be able to access more information concerning them. St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 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 3 X 2 X 4 3 3 3 X St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 YA5 Regulation 5(1) Requirement Each service user and/or their relative must be supplied with a copy of the terms and conditions and contract, in a format appropriate to their needs. The appointed Manager must apply for registration. Timescale for action 31/10/06 2 YA37 8 31/12/06 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 YA17 Good Practice Recommendations Staff should review the menus to try to approximate the Department of Health’s healthy eating guidelines. St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 St Alban`s Cottage DS0000001496.V302744.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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