Inspection on 07/06/07 for St Andrew`s House

This inspection was carried out on 7th June 2007.

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

The inspector found 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

St Andrew`s House 05/01/06

St Andrew`s House 11/07/05

St Andrew`s House 20/09/04

St Andrew`s House 21/06/04

Similar services:

Southfields

Thorndene

Insight - Eastchurch

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 St Andrew`s House St Andrew`s House 93 Downland Way Tattenham Corner Epsom Surrey KT18 5SH Lead Inspector Joseph Croft Unannounced Inspection 7th June 2007 09:45 St Andrew`s House DS0000013794.V337460.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 Andrew`s House DS0000013794.V337460.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 Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Andrew`s House Address 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) St Andrew`s House 93 Downland Way Tattenham Corner Epsom Surrey KT18 5SH 01737 210304 Mrs R Young Mrs R Young Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: Learning disability (LD) 36 - 65 years and LD(E) 54 years and over. The number of persons for whom residential accommodation and personal care is provided at any one time shall not exceed three (4). 5th January 2006 Date of last inspection Brief Description of the Service: St Andrews House is a terraced house located in Epsom Downs at Tattenham Corner. The home is registered to provide personal care for up to four service Users with learning disabilities. The service Users’ accommodation comprises of 4 single bedrooms, lounge, kitchen, dining room, toilets and bathroom. The home has its own well-kept garden and is located close to the local village shops and is a short distance from Epsom town centre, which has a good range of shopping and leisure facilities. The home has its own vehicle to transport the Service Users. The physical standard of the Home is exceptional and it continues to offer an extremely high level of care to its Service Users. Weekly fees range from £740 to £780. St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 7th June 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. This visit was undertaken by Regulation Inspector Mr Joe Croft and took five hours, commencing at 9:45 and concluding at 15:15. The inspection process included a tour of the premises and sampling of one resident’s care plan and risk assessments. Other documents sampled included the staff duty rota, menu, policies and procedures and records of medication. The Inspector had discussions with the Registered Manager who is also the owner, the deputy manager and one senior care staff on duty. There are three residents living at the home, one was attending a day centre on the day of the site visit. One resident was used as part of the case tracking process, and discussions took place with this resident. Residents were observed to be appropriately cared for, with staff attending to and supporting individuals as and when required. Staff spoken to were complimentary about the manager of the home. At the time of the site visit the Commission For Social Care Inspection had not received a completed Annual Quality Assurance Assessment (AQAA) or comment cards from residents, their relatives or other associated professionals. The manager informed the Inspector that the completed AQAA had been posted on the 4th June 2007. The AQAA was received the day after this site visit. The inspector would like to thank the members of staff and residents for their cooperation during this visit. What the service does well: People who use services are provided with information about the home. Assessment documentation, care plans and risk assessments in place to ensure residents’ needs are met. Residents are encouraged by staff to participate in a range of activities both within the home and the local community. A healthy and balanced diet is provided for residents. Physical and health care is offered in such a way as to promote service users’ privacy and dignity. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. The home provides good communal and individual living space making it a safe and comfortable place to live. The arrangements for management and administration ensure the safety of residents is promoted and safeguarded. St Andrew`s House DS0000013794.V337460.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. St Andrew`s House DS0000013794.V337460.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 Andrew`s House DS0000013794.V337460.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): Standards 1 and 2 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with information about the home. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: The manager informed the Inspector that residents receive a Statement of Purpose and Service Users Guide when they move into the home. Both of these documents are currently being reviewed, and copies will be forwarded to the Commission For Social Care Inspection on completion. The home currently has three female residents, and the most recent admission to the home was used as part of the case tracking process. The manager had received a pre-admission assessment from the care manager that was dated 28th March 2006. This included information in regard to personal and health care needs and ethnicity. The manager undertakes an assessment for the home, and informed the Inspector that only residents whose assessed needs can be met are accepted. During discussions, one resident informed the Inspector that she remembers the manager visiting and asking her lots of questions. This resident stated St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 9 that she did visit the home prior to moving in, and that she is “very happy living here.” The home has an Admissions Policy and Procedure. St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have care plans and risk assessments in place, which ensures their needs are met, and they are supported by staff to lead active lives. EVIDENCE: The care file sampled contained a care plan that was last reviewed on the 4th April 2007. The care plan included information in regard to the residents’ personal and health care needs, self-help skills, community living, choices, activities and religion. The care plan had been signed and dated by the resident. Evidence was viewed that a statutory review had been undertaken. During discussion, staff informed the Inspector that residents are provided with the opportunity to make decisions, and these are recorded in the daily notes, which were viewed during this site visit. The care file sampled included risk assessments pertaining to the individual and had recently been reviewed. These include risks in regard to behaviour, accessing the community, shopping and health care. It was noted that each St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 11 member of staff and the resident had signed to say they had read and understood the risk assessments. St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are encouraged by staff to participate in a range of activities both within the home and the local community. A healthy and balanced diet is provided for residents. EVIDENCE: One resident is currently in part time employment, which unfortunately is due to cease at the end of June. The manager informed the Inspector that staff and the resident’s care manager are actively seeking alternative employment for her. Other residents in the home attend day centres through out the week. During discussions, the manager and staff informed the Inspector that a wide range of activities are provided for residents that include shopping, cinema, restaurants, regular visits to seaside venues and local towns. This was confirmed during discussions with one of the residents. It was noted one resident had a list of her weekly activities in her bedroom. Residents have had annual holidays in Portugal and Spain, and are looking forward to going to St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 13 Spain again this year. The Inspector was shown photographs of previous holidays taken in European holiday resorts. The Inspector was informed that residents are able to meet with people from other care homes in the locality as well as making friends at day centres. All three residents living at the home are White British, and their religion is Church of England. One resident informed the Inspector that she does not practice her religion, but gave details of the arrangements she has made for when she comes to the end of her life, including the name of the vicar to conduct the ceremony. The staff stated the other two residents practice their religion as and when they choose to. The manager and staff informed the Inspector that racial, religious and cultural needs of any resident living at the home would be respected and promoted. The home has a diverse staff team. Staff at the home support residents to maintain family contact and friendships. There are no restrictions on visitors to the home, and residents are able meet visitors in the privacy of their bedrooms. Staff informed the Inspector that they respect individuals’ privacy and dignity through knocking on bedroom doors before entering, and call residents by their preferred names. Residents receive their mail and telephone calls in private. Staff were observed to be interacting with residents in a positive manner, and addressing them by their first names. Staff support residents with household chores such as laundry, changing their bed linen and some cooking. Menus were viewed during this site visit. Menus included fresh meat, fish, fresh vegetables and fruit, and meals from other cultural backgrounds. During the site visit residents were observed having hot drinks and snacks as and when required. During discussions one resident informed the Inspector that the food was good, that she “loves it.” The home does not employ a cook, and staff attend to the cooking duties. It was noted that all staff had received training in regard to food handling and hygiene, however this is now due to be updated, which the manager stated would be organised immediately. Food was appropriately stored in the kitchen and records of fridge/freezer and cooking temperatures were being maintained. However, it was noted that some foods being kept in one fridge had passed their use by date. This was immediately discarded during the site visit. St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 were assessed. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are protected by the home’s recording of medication procedures. Physical and health care is offered in such a way as to promote service users’ privacy and dignity. EVIDENCE: The care plan sampled provided evidence that personal care and support required was recorded. Staff informed the Inspector that residents are able to attend to their personal needs, but support is offered as and when appropriate. Personal care is always provided in the privacy of residents’ bedrooms. Each of the three residents have a 24 Hour Care Plan that details residents wishes of how staff should attend to their personal care needs. Residents are able to choose the time they go to bed, and get up in the morning, depending on the activities they have chosen for that day. Residents were observed wearing their own smart clothes that they had chosen to wear. One resident informed the Inspector that she liked shopping for nice clothes. The manager informed the Inspector that a Physiotherapist visits the home on an annual basis and provides training on manual handling. St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 15 Residents are registered with the local GP practice, Dentist, Optician, and have access to all National Health Services. Records of appointments and annual check ups are maintained, and monthly monitoring of weights is recorded. The home uses the Medical Administration Record sheets (MARs) for the recording of medicines. The home maintains records of medicines received and returned to the Pharmacist. Medicines are appropriately stored in a locked metal medicine cabinet. The MAR sheet for the resident who was part of the case tracking was sampled. The medicines kept in the home did not tally with the records maintained on the MAR sheets. Two prescribed medications sampled had too many tablets left over. All dates for the administration had been signed. The manager informed the Inspector this was due to the fact that the GP had provided the first lots of medication to the home, and this would be addressed immediately. The manager informed the Inspector that she would consult with the pharmacy in regard to using the Monitored Dose System (MDS) for the home. The Inspector was informed that only the manager and deputy manager dispense medication. The manager informed the Inspector that she has booked training for all staff in regard to the safe administration of medication for the 3rd July 2007. Staff informed the Inspector that no resident is self-medicating or taking a Controlled Drug. Residents’ had been offered the opportunity to self medicates, but they all refused. The home has a Medication Policy and Procedure dated April 2006. St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Staff having knowledge of adult protection issues protect residents. EVIDENCE: The Commission For Social Care Inspection has not received any concerns, complaints or allegations in regard to the home. The home has a Complaints Policy and Procedure and a copy of this is included in the Service Users Guide. The Complaints procedure includes the timescales for responding to complainants, and informs that the Commission For Social Care Inspection can be contacted if the complainant is not satisfied with the outcome of a complaint. Residents spoken to state they would talk to the home’s manager if they needed to make a complaint, however, they have never had the need to. The manager informed the Inspector that the home has never received a complaint. The home has a Protection of Vulnerable Adults Policy, however, it did not have a copy of the Surrey Multi-Agency Procedures of February 2005. A requirement has been made that the Protection of Vulnerable Adults policy and procedure must be reviewed to ensure it is written in line with the Surrey Multi-Agency guidelines on the Protection of Vulnerable Adults of February 2005. It was noted that only one member of staff had received training at her previous employment in regard to the Protection of Vulnerable Adults. There was no evidence available in regard to other staff having received this training. St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 17 Some staff have commenced a distant learning training in regard to the Protection of Vulnerable Adults. The manager informed the Inspector that external training has been arranged for three members of staff for 19th July 2007. The manager stated that she has applied to attend the Surrey Multi – Agency Training for the Protection of Vulnerable Adults, and hopes to secure a place for September 2007. During discussions, staff stated they would report all suspicion of abuse to the manager, and would not hesitate to report bad practice. The manager informed the Inspector that residents conduct their own financial affairs. St Andrew`s House DS0000013794.V337460.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are provided with good communal and individual living space making it a safe and comfortable place to live. EVIDENCE: A tour of the premises was undertaken. The accommodation comprises of 4 single bedrooms, lounge, kitchen/dining room, toilets and bathroom. The home has its own well-maintained garden, which has flowers and potted plants throughout. Bedrooms and communal spaces were brightly decorated, and residents had their own personal possessions that included photographs, televisions and radios. One resident stated that she liked her bedroom and that she has her own things in it. Residents have access to all communal areas of the home. During discussions residents and staff stated the home is always clean and tidy. Toilets and bathrooms had anti-bacterial liquid soap and paper towels. On the day of the site visit the home was very clean, tidy and free from offensive odours. The home has a policy in regard to Infection Control. St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 19 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): Standards 32, 34, 35 and 36 were assessed. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by the organisations recruitment policy and procedures. Attention in regard to records of staff working at the home must be addressed. EVIDENCE: The home currently employs seven members of staff. The manager informed the Inspector that there is a minimum of two members of staff on duty each shift, and one member of staff covers the sleep in duty each night. However, this could not be evidenced as the duty rota viewed was incomplete, and did not provided evidence of the amount of staff on duty. A requirement has been made that a copy of the duty rota of persons actually working at the care home must be maintained at all times. During discussion, one resident informed the Inspector that there is always enough staff on duty that they help her when she needs it, and she is always taken to her external activities by staff. This resident also stated that staff are very nice and look after the residents well. The manager informed the Inspector that all staff working at the care home are qualified nurses and those who are not, hold the minimum of NVQ level 2. St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 20 During discussions, the manager stated that registering staff with Skills For Care is to be explored. The manager has obtained an Induction pack from an external agency that is to be used when new staff are recruited. The home has a Recruitment Policy and Procedure that is followed when recruiting new staff. The manager stated that the staff team has been stable, and the last recruitment of staff was in 2005. Two recruitment files were chosen at random to sample. These contained the appropriate information required under Schedule 2 of The Care Home Regulations 2001 as amended. Criminal Record Bureau reference numbers were maintained for all staff. The manager stated that she maintains proof of identity for all staff working at the care home, however, these were not viewed during this site visit. During the past twelve months staff have received training in regard to Manual Handling, Schizophrenia and Mental Illness. There is not an annual development plan for the home, however, the manager stated that this would be produced and would include training and development of staff. It was noted that care staff are not receiving the minimum of six one to one formal supervision per year. A recommendation has been made in regard to this. St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 21 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): Standards 37, 39 and 42 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for management and administration ensure the safety of residents is promoted and safeguarded. EVIDENCE: The registered manager, who is also the owner of the care home, informed the Inspector that she is a Registered General Nurse for people with Learning Disability. The manager informed the Inspector that her pin number is active and due for renewal in March 2008. The manager has been working at the home since 1999, has completed the NVQ level 4 and the Registered Managers Award (RMA). Feedback is sought from residents through individual and group discussions. The Inspector viewed minutes of monthly resident meetings. Annual surveys of residents, their relatives and other associated professionals had not been undertaken to ascertain their views of the care provided to residents. The manager informed the Inspector that this would be addressed. St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 22 The home has a variety of Policies and Procedures, some of which were sampled during this site visit. Staff had received mandatory training in Food Hygiene and Manual Handling. It was noted that staff had not attended training in regard to Infection Control or Fire Safety, and only three staff had received training on First Aid. An inhouse training pack has been purchased for the Infection Control training. The manager informed the Inspector that training in regard to First Aid and Fire Safety would be arranged for all staff. Health and Safety records evidenced during this site visit included Portable Electrical Appliance Testing, 26/6/06, Gas, 2/9/06, Fire Extinguishers, 16/6/06, Fire Alarms, June 2006. Evidence of fire drills and weekly tests of alarms were viewed. Fire risk assessments have been produced for the home. St Andrew`s House DS0000013794.V337460.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 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 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 X 3 X LIFESTYLES Standard No Score 11 3 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 3 X 2 X X 3 X St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 24 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 YA23 Regulation 13 (6) Requirement Timescale for action 07/07/07 2. 3. YA32 YA39 17 (2) Sch 4 (7) 24 The Protection of Vulnerable Adults Policy and Procedure must be reviewed to ensure it contains the appropriate information, and is written in line with the Surrey Multi-Agency guidelines on the Protection of Vulnerable Adults of February 2005. A copy of the duty rota of 14/06/07 persons actually working at the care home must be maintained. The home must develop an 07/08/07 annual questionnaire for residents, their families and other associated professionals to ascertain their views on the care provided. 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 YA36 Good Practice Recommendations It is strongly recommended that all staff receive a minimum of six one-to-one formal and recorded DS0000013794.V337460.R01.S.doc Version 5.2 Page 25 St Andrew`s House supervision sessions per year. St Andrew`s House DS0000013794.V337460.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 St Andrew`s House DS0000013794.V337460.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!