Inspection on 17/07/06 for St Albans Close

This inspection was carried out on 17th July 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Albans Close 28/02/06

St Albans Close 18/07/05

St Albans Close 21/01/05

St Albans Close 27/05/04

St Albans Close 02/03/04

St Albans Close 22/01/03

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

CARE HOME ADULTS 18-65 St Albans Close 1-2 St Albans Close Northampton Northants NN3 2RJ Lead Inspector Mrs Kathy Jones Unannounced Inspection 17th July 2006 08:10 DS0000012920.V304346.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 DS0000012920.V304346.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. DS0000012920.V304346.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Albans Close Address 1-2 St Albans Close Northampton Northants NN3 2RJ 01604 785775 01604 415489 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) Royal Mencap Society Vacant Care Home 7 Category(ies) of Learning disability (7) registration, with number of places DS0000012920.V304346.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No additional conditions. Date of last inspection 28th February 2006 Brief Description of the Service: St Albans Close is a residential care home providing personal care and support to 7 men with learning disabilities; a service provided by the national charity Mencap. St Albans Close is situated on a residential estate on the outskirts of Northampton Town Centre with access to a range of community facilities. The Home comprises two semi-detached properties, which have been merged, and undergone major refurbishment to create a spacious and homely environment suited to the needs of the service users. Gardens to the rear of the house have been landscaped and provide spacious outdoor facilities. A small self-contained flat has been created on the first floor and is occupied by one of the residents’ who has a high level of independence and self-skills. Staff provide support and supervision as needed, the service user concerned is able to access all other facilities and services of the Home on an equal basis. Information about fees charged to funding bodies was not available at the time of this inspection. In addition to these fees, residents pay between £62.35 and £94.45 per week. The fees include personal care, accommodation, meals, laundry and a seven day holiday. Additional charges include chiropody, toiletries, clothing and travel. DS0000012920.V304346.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. All standards identified as ‘key’ standards and highlighted through the report were inspected with the exception of standard 31, which relates to the registered manager. Currently there is no registered manager in post however the acting manager advised that she has submitted an application for registration. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of existing evidence, pre-inspection planning, an unannounced inspection visit to the home and drawing together all of the evidence gathered. The review of evidence and pre-inspection planning was carried out over the period of half a day and involved reviewing the reports of the last two statutory inspections, the latest carried out in February 2006. The service history was reviewed, which details all contact with the home including notifications of events reported by the home, complaints, protection of vulnerable adults investigations and telephone calls. The information gathered assisted with planning the particular areas to be inspected during the visit. The unannounced inspection visit covered the morning and early afternoon of a weekday. The inspection was carried out by ‘case tracking’ which involves selecting residents’ and tracking their care and experiences through review of their records, observation of interactions with care staff and care practices. The inspector observed the early morning routine and had planned to talk to one resident prior to him going to work. Unfortunately the taxi arrived early and this was not possible. Conversations with residents’ were limited due to communication difficulties and the findings of this inspection in relation to residents’ experiences are based mainly on observations. The management of residents’ medication was reviewed. Staff training was discussed with staff and two files for newly recruited staff were reviewed to check the adequacy of the recruitment process. Discussion took place and feedback was given to the acting manager throughout the inspection. DS0000012920.V304346.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: Information about the assessed needs of residents was not available and it was difficult to ascertain how judgements had been formed about individual residents’ needs. This information needs to be clarified to provide a basis for planning residents’ care. Care plans and risk assessments need to include more detail and be kept up to date as they were found not to be reflective of residents’ current needs. Care plans are an important tool to guide staff in the actions they need to take to provide appropriate and consistent support and care for residents. At the time of the inspection there were some staff vacancies, which is putting some pressure on existing staff who were working additional hours. Discussion about training to meet residents’ specific needs identified that staff have not received any autism training. Advice was given to consider the assessed needs of residents and base the training on this. DS0000012920.V304346.R01.S.doc Version 5.2 Page 7 The quality assurance system needs to be developed to ensure that any shortfalls can be quickly identified and addressed ensuring a continued good standard of care to residents’. 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. DS0000012920.V304346.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 DS0000012920.V304346.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. There was no evidence that the assessment process ensured that the needs of people admitted to the home. EVIDENCE: Previous inspection reports identify that the statement of purpose does not include all of the information required by the Care Homes Regulations 2001 and requirements to update it have been outstanding since August 2004. The regulations require each home to have a statement of purpose, which sets out the aims and objectives and details the facilities and services provided. The information is needed to help prospective residents’; their families and placing authorities make a decision about the suitability of the home. It also provides confirmation of what can be expected to existing residents’ and their families. The acting manager advised that work has been carried out on the statement of purpose and has confirmed that it only requires the addition of some photographs. The inspector was satisfied that work is almost complete and has accepted a commitment to forward a copy to the Commission for Social Care Inspection by the end of July 2006. In view of this the requirement is not repeated in this report. DS0000012920.V304346.R01.S.doc Version 5.2 Page 10 No new residents’ have been admitted to the home in the last two years. Review of the records for the most recently admitted resident identified that there were no copies of assessments of need carried out by the placing authority or the home. It was therefore difficult to confirm the adequacy of the assessment process in ensuring that the needs of people admitted to the home can be met. Care plans included information about particular conditions such as autism and paranoia however there was no information to confirm how this had been assessed and who by. The acting manager advised that there had been a shortfall in records when she took over the home and has acknowledged the need to gather this baseline information about any diagnosed conditions in order to ensure residents’ needs can be fully met. The acting manager confirmed that Mencap have an assessment tool and a clear admission procedure which includes obtaining copies of all relevant assessments. Assurance were given that Mencap procedures would be followed in future to ensure that they could demonstrate how an individuals needs would be met. Review of a residents file identified that there was a copy of a licence agreement signed by the resident, which detailed the charge, made to the resident by the housing association and Mencap. The document stated that the charge was for accommodation, food, heat, light and other services including a contribution towards support or care. Details of total fees charged and how individual charges to residents are calculated were not available. DS0000012920.V304346.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. The care and support appears to be good however the lack of up to date care plans has the potential to put residents at risk of their needs and preferences not being fully met. EVIDENCE: A sample check of three residents’ care files, observations of residents’ and discussion with staff identified that the care plans and risk assessments in place did not reflect residents’ current needs. For example there was no evidence of care plans drawn up in April 2005 being reviewed. In one case it was apparent that a resident required less assistance from staff, than the care plan indicated, creating a risk of staff taking away their independence unnecessarily. In another instance a resident had particular routines and tasks that were important to them, which were not included. There was also no care plan guidance in place for staff to guide them in meeting the needs of a resident with dementia whose needs had changed. DS0000012920.V304346.R01.S.doc Version 5.2 Page 12 The acting manager confirmed that she was aware that this was the case and that she had identified this as an area to be addressed and planned to bring them up to date by the end of September 2006. Care plans are important tools in guiding staff as to the actions required to meet residents’ needs and preferences. The need to prioritise any care plans where a risk has been identified and for plans to be used as a working tool was discussed. A staff member confirmed that residents’ were fully involved in the development of their plans and staff understood the importance of their involvement. Discussion with staff and the acting manager indicated that changes of practice have occurred which are providing residents’ with more choice, independence, and the ability to make decisions and take responsible risks. The acting manager acknowledged that more work is still required and that care plans need to support residents in achieving their agreed goals. DS0000012920.V304346.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 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 outcome area is good. This judgement has been made using all the available evidence including a visit to the service. Residents’ receive support in accessing community and leisure activities and maintaining contact with their families and are encouraged to develop independent living skills. EVIDENCE: On arrival at the home on the morning of inspection some residents were just about to leave for their various day activities. Four of the seven residents attend day activities away from the home and two of them spoken to briefly appeared happy with their placements. The acting manager advised that two of the residents’ are in work related schemes where a small salary is paid. She confirmed that consideration to individual skills is given in relation to the possibility of gaining employment and that this will be reviewed regularly. Staff and the acting manager confirmed that residents have opportunities to access community facilities and leisure activities. They acknowledged that DS0000012920.V304346.R01.S.doc Version 5.2 Page 14 lately there had been some limitations in leisure activities due to staffing difficulties and the range of different needs and interests of residents. Records reviewed for one resident showed visits and outings with family, shopping, and trips to the bank, post office and optician. Residents are supported to attend church if they wish and recently a visitor from church has been visiting a resident who has not been able to attend due to deterioration in health. Three residents’ were at home on the day of inspection. It was an exceptionally hot day and the day was spent quietly indoors with staff trying to keep cool. Residents’ are able to have a seven day holiday each year. The acting manager advised that the holidays are arranged according to residents’ choices and that all seven residents do not go together. Brochures, a map and DVD’s are obtained to assist residents’ in making a choice. Residents’ are encouraged to treat the house as their home and are able to have visitors, which they are able to see in private. Staff provide some support for one resident in preparing and cooking a meal for a friend. Discussion with the acting manager and staff confirmed that they recognise the rights of residents’ and that some changes to practices are gradually being made. One example of this is residents’ are now going out of the home for appointments such as chiropody enabling them to access services in the same way as other members of the public. One resident travels to work independently by bus. Residents are also encouraged to take responsibility with support from staff for household tasks according to their abilities. Two residents who were at home on the day of inspection indicated that they were happy with the meals provided. Records of meals are kept. The acting manager advised that normally these are planned a week in advance with the residents however alterations were being made due to the exceptionally hot weather. A sample check of the meals provided showed quite a bit of repetition and the acting manager confirmed that she is looking at ways of achieving a varied and balanced diet while maintaining choice for residents. Residents are aware of where the food and drink is kept and indicated that it was freely available. Drinks were being encouraged on this hot day. DS0000012920.V304346.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. Residents are supported with their personal care, and health care services are accessed on their behalf. However more thorough assessment, review of needs, care planning and monitoring needs to be in place to ensure needs are fully met. EVIDENCE: Discussions with staff indicated that residents receive a good level of personal support however this was not easily evidenced through the records. Staff are respectful of residents’ privacy and dignity. Discussion with staff and observations indicated that they are caring and keen to work in the best interests of residents’. Times for getting up and going to bed are flexible and based on residents’ preferences and the activities they are involved in. One resident whose needs have changed was reluctant to get up, gentle encouragement was being used and advice is being sought from health professionals regarding changed routines. Records showed that various relevant health professionals have been accessed on behalf of residents’ and where appropriate advice sought on their care. For DS0000012920.V304346.R01.S.doc Version 5.2 Page 16 example a physiotherapist has assessed the needs of four residents and has arranged to visit the home to talk to staff about the support needed for individual residents in improving mobility. As identified previously in this report the acting manager is trying where possible and appropriate to arrange healthcare appointments outside the home in line with other members of the public. Advice has been given to ascertain residents’ individual diagnosis and plans are in place and staff have the necessary training to ensure all needs are fully met. For example records indicated that a resident has had mental health needs however it was not clear that this was a formal diagnosis and how the needs were being met. A sample check of residents’ medication confirmed that medication received into the home for residents’ is recorded, securely stored and that a signed record is kept of all medication administered. One resident manages their own medication and has been provided with a lockable storage box to keep the medication securely. DS0000012920.V304346.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. Complaints are taken seriously and staff are aware of their responsibilities in protecting residents’. EVIDENCE: At the time of the previous inspection in February 2005 Mencap had commissioned an investigation into allegations that complaints about verbal and physical abuse against a member of staff were racially motivated. Mencap also carried out a review of their investigation as the Commission for Social Care Inspection (CSCI) had received a complaint about this. CSCI reviewed the reports of the investigations and were satisfied that the matters had been appropriately investigated. Discussions with black and white staff during the inspection confirmed that they felt properly supported in their roles and that all staff at the home are now working well as a team. Staff have received training in protecting vulnerable adults and were clear about their responsibilities to report any concerns that may arise. No other complaints were identified through CSCI records or the complaints record kept in the home. DS0000012920.V304346.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. The standard of the environment is good providing residents’ with a clean, comfortable and homely place to live. EVIDENCE: Communal areas and one resident’s bedroom were seen during the inspection. The home was found to be clean and comfortably furnished. The layout of the home is such that there are separate communal areas where residents’ can spend time alone if they wish. Residents’ have free access to all parts of the home including the garden, which is a good size and enclosed. The garden was well maintained at the time of the inspection and there are tables and chairs for eating or sitting outside. A parasol provided some shade. All residents have single bedrooms with one having a flat within the house enabling him to live semi-independently. Three bedrooms are located on the first floor of the house; these have en-suite toilets and showers. The three bedrooms on the ground floor have an en-suite toilet and a large washbasin, which can be accessed by a wheelchair user. There is also a large communal DS0000012920.V304346.R01.S.doc Version 5.2 Page 19 bathroom on the ground floor, which has a bath with a hoist for assisted bathing. Residents’ have locks on their bedroom doors, which enable them to have some privacy however rooms can be accessed in the case of emergency. The locks are the same type as used on the bathroom door, which needed to be turned twice to release. Advice was given to ensure that residents’ are all able to release the lock. DS0000012920.V304346.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. Staff appear to be working together as a team however to enable them to fully meet residents needs however additional training based on their assessed needs is required. EVIDENCE: The staff team have gone through a difficult period and some staff have left. At the time of the inspection there were some staff vacancies, which is putting some pressure on existing staff who were working additional hours. The acting manager was also covering some of the shifts however she heard during the inspection that a good response had been received to an advertisement placed, so was hopeful of filling the vacancies. Staff spoken to during the inspection appeared committed to working to support and where possible improve the lives of residents’. Discussion during the inspection indicated that the work they have carried out has resulted in some increased independence and confidence for one resident in particular. While specific issues relating to the complaint referred to in the complaints section of the report were not discussed during the inspection staff confirmed that they felt supported by the acting manager and that they were able to DS0000012920.V304346.R01.S.doc Version 5.2 Page 21 work together as a team. Some care plans were reviewed with a member of staff and advice and suggestions for improvements appeared to be welcomed. A sample check of staff files confirmed that references and criminal record bureau clearances are received prior to staff working in the home providing protection for residents. Advice was given regarding the need to check the adequacy and status of the references as for one file checked they appeared to have been submitted by colleagues rather than an employer. The acting manager advised that she had received some training in recruitment procedures, particularly relating to the recruitment of overseas staff. One member of staff has completed a National Vocational Qualification at level 3 (NVQ2) in care, which covers basic care practices and two others are working towards the qualification. The acting manager confirmed that the qualification staff are undertaking is based on working with adults with a learning disability. The ratio of staff holding a qualification in care is currently below the recommended minimum of 50 . Staff have received training in various areas, which include: equality and diversity, adult protection, epilepsy, person centred approach, some dementia and first aid. The acting manager has identified the need for some additional dementia care training due to the increased needs of a resident. Discussion about training to meet residents’ specific needs identified that staff have not received any autism training. Advice was given to consider the assessed needs of residents and base the training on this. DS0000012920.V304346.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. The acting manager is working with the staff team to manage the home in the best interests of residents’, however there must be evidence that good quality assurance processes are implemented to ensure standards are maintained. EVIDENCE: Standard 31, which is one of the key standards, has not been assessed, as the home does not currently have a registered manager. There is a manager in post who advised that she has just submitted an application for registration to the Commission for Social Care Inspection. As the manager has not yet been registered with the Commission for Social Care Inspection, she is referred to as the acting manager in this report. DS0000012920.V304346.R01.S.doc Version 5.2 Page 23 Since the last inspection in February 2006 the home has been without permanent management support for most of this period. Some temporary support has been provided from other Mencap homes. Review of previous statutory requirements identifies that they have been met with the exception of that relating to the statement of purpose. The acting manager has confirmed that this has now almost been completed. While some shortfalls have been identified in this report, which relate to the management of the home it is acknowledged that the acting manager demonstrated a commitment to the provision of a good standard of care and support to residents’. The acting manager was aware of some of the documentation, which forms part of the organisations quality assurance processes. However documentation to confirm that views have been sought from residents, relatives and professionals and a full review of all aspects of the service has actually been carried out were not available. This is an area to be developed to ensure that any shortfalls can be quickly identified and addressed ensuring a continued good standard of care to residents’. No health and safety hazards were identified during the inspection and staff confirmed that they receive training in safe working practices and first aid. DS0000012920.V304346.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 2 X X 3 X DS0000012920.V304346.R01.S.doc Version 5.2 Page 25 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 YA6 YA9 2. YA32 YA35 12 (1) (a & b) Regulation 12 (1) (a & b) Requirement Timescale for action 30/09/06 Care plans and risk assessments must reflect residents’ current needs and be sufficiently detailed to guide staff in meeting their needs. Staff training must be provided 30/09/06 to meet the specific assessed needs of residents including training on autism. 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. Refer to Standard YA2 YA7 Good Practice Recommendations The assessed needs and diagnosis of all residents must be established to ensure their needs can be fully met. Care plans should demonstrate how work is being carried out to support residents in making decisions and achieving their agreed goals. DS0000012920.V304346.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 DS0000012920.V304346.R01.S.doc Version 5.2 Page 27 - 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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