Inspection on 11/08/06 for St Annes Road East (85)

This inspection was carried out on 11th August 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Annes Road East (85) 04/09/09

St Annes Road East (85) 13/01/09

St Annes Road East (85) 01/12/05

St Annes Road East (85) 09/08/05

St Annes Road East (85) 16/12/04

St Annes Road East (85) 11/05/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 St Annes Road East (85) 85 St Annes Road East St Annes Lancashire FY8 3NF Lead Inspector Phil McConnell Unannounced Inspection 11th & 15 August 2006 09:30 th St Annes Road East (85) DS0000009887.V303943.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 Annes Road East (85) DS0000009887.V303943.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 Annes Road East (85) DS0000009887.V303943.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Annes Road East (85) Address 85 St Annes Road East St Annes Lancashire FY8 3NF 01253 712547 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 Mr Stephen Turner Care Home 6 Category(ies) of Learning disability (6) registration, with number of places St Annes Road East (85) DS0000009887.V303943.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 Brief Description of the Service: 85 St Annes Road East is a small care home for adults with learning disabilities, registered for six people. The well-established national charitable organisation United Response is the registered provider. The home is a semi-detached three-storey house providing good access to local services and amenities. The organisation provides a vehicle to enable people living at the home to take part in leisure activities and access amenities. The staff team support individuals in all aspects of daily living according to their assessed needs and as identified via the care planning process. Individuals are supported and encouraged to develop their independence and take part in all aspects of community living. The service adopts an active support approach, providing people with practical day-to-day support, in order that individuals can take as much control of their lives as possible. The staff team are supported by an experienced management team and an organisation, which clearly values its employees and the people who use the service. St Annes Road East (85) DS0000009887.V303943.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The assimilation of information since the last published report by the Commission for Social Care Inspection (CSCI) and an unannounced visit to the home, were all used to fully assess the key standards identified in the National Minimum Standards. (Only one service users’ questionnaire was received, no comment cards were received from relatives, GP’s or other professionals). The inspection visit took place on the 10th of August, with a follow up visit taking place on the 15th of August in order to speak with the house manager, who was not on duty at the initial visit. During the first visit to the home three service users files were examined along with policies and procedures and there was the opportunity to observe the care provided to the service users and the interaction between them and the staff who were on duty throughout the day. There was the opportunity to have conversations with some of the service users, some of the staff team and the house manager on the second visit. What the service does well: It was evident that generally there is a commitment from the team to provide good quality care and support, with appropriate and relevant training being provided to help ensure that the service users needs are being met. Over 80 of the staff team have been successful in achieving the NVQ level 2 award in care. The referral to the ‘Additional Support Team’ to provide training in ‘Positive behavioural Analysis’ is good practice, helping to demonstrate that the organisation is pro-active in obtaining the expertise of other professionals, for the benefit of the service users. (See staffing section). The team are proactive in promoting independence, inclusion and community participation. A lot of work has been done to further improve the team dynamics and it is apparent that this is having a positive effect on the service users. St Annes Road East (85) DS0000009887.V303943.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. St Annes Road East (85) DS0000009887.V303943.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 Annes Road East (85) DS0000009887.V303943.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 “Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service”. Files contained limited information regarding individual admissions, however, a good process is in place, to help ensure that any future admissions to the home would be dealt with appropriately, giving the assurance that individuals assessed needs would be met. EVIDENCE: Three service users’ files were examined and all of their files were limited in information with regards to pre-admission assessments. In discussion with some staff members, it was commented that there have been a lot of changes for the ‘better’ in the last 18 months or so and it was commented, “If anyone new moved in now it would be much better”. The service users’ files did however contain other relevant and thorough information, with which it was possible to identify and determine individuals care needs, including: Intimate and personal support plans, Medical profiles, Learning logs which indicated what a person liked or disliked about a particular activity, Individual risk assessments and one service user had very thorough and specific key points in their support plan, which were identified as being ‘essential for this persons’ wellbeing’. St Annes Road East (85) DS0000009887.V303943.R01.S.doc Version 5.2 Page 9 A couple of the service users’ files did not contain admission dates and the files were generally disorganised. The house manager was informed of these minor issues and an assurance was given that they will be addressed. The policy and procedures relating to a service user moving into the home were examined and found to be informative, with clear guidance given of the necessary procedures needed to be planned and taken to ensure that as smooth a transition as possible would take place, for a person moving to St Annes Rd East. St Annes Road East (85) DS0000009887.V303943.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. “Quality in this outcome area is ‘Adequate’. This judgement was made using available evidence including a visit to this service”. Satisfactory care plans and risk assessments are in place, helping to ensure that individuals’ needs are being met. Service users are supported to make appropriate decisions and take assessed risks in their lives. Thereby empowering people to be as independent as possible. EVIDENCE: Service users’ have care plans, which are reviewed on a six monthly basis. Care plans contained detailed and concise information to help assist the care and support delivery for individual service users. One persons’ care plan had specific strategies and protocols for helping to manage some behavioural problems that this person has been demonstrating. In speaking to staff members and observing the support given to this person, it was apparent that the strategies used are generally working. St Annes Road East (85) DS0000009887.V303943.R01.S.doc Version 5.2 Page 11 The approach that was used was patient, tolerant and understanding with explanation given to the individual, giving time for the person to respond. Overall there was inclusion and equality demonstrated towards this service user, which was generally well received. There was a key worker (service users have a named worker) system in place; helping to promote trust and confidence between the service user and the staff member, thereby, helping to ensure a service users’ changing needs are identified and acted upon as quickly as possible. One service user has profound hearing and speech difficulties and in speaking to different members of staff, there was a difference of understanding of how to communicate with this person. Following the visit there was the opportunity to give some feedback to the house manager and it was stated that the staff team will be working in a consistent and corporate way to further develop communication with this service user and a ‘pictorial book’ containing photographs and specific pictures is going to be used. Advice and help from other professionals has already been accessed, including a speech and language therapist. As already mentioned there were individual risk assessments in place, with specific information and guidance, in order to promote and encourage independence. The key-worker is responsible for reviewing these risk assessments on a six monthly basis or when an identified risk or change is recognised. There was evidence that a referral has been made to an advocacy service for an advocate to work with one of the service users, in order for the person to have some professional help and guidance. This demonstrates that confidentiality, choice and persons’ rights are taken seriously, with people being empowered and enabled to make decisions in their lives. St Annes Road East (85) DS0000009887.V303943.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. “Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service”. Good and varied activities are evident, helping to provide stimulation and motivation for service users. Community participation and inclusion is actively demonstrated and evidenced in the recreational activities that people are involved in. Good relationships exist between service users, staff and families, helping to promote a caring and supportive environment for vulnerable people. Varied menus are part of a healthy eating plan, which is encouraged by the staff team and participated in and welcomed by the service users. EVIDENCE: It was evident that the service users attend varied activities throughout the week including: a sensory drama workshop, dancing class, cooking lessons, swimming, meals out, bowling, a weight watchers class and regular days out. St Annes Road East (85) DS0000009887.V303943.R01.S.doc Version 5.2 Page 13 During both of the inspection visits it was observed that two of the service users were out for most of the day, participating in different supported activities. There was the opportunity to have discussions with some of the service users and they were fully aware of the activities available and some of the comments were, “I love going dancing, I really enjoy the dancing on a Wednesday” and “I like going for pub lunches”. In discussion with the house manager and some staff members it is apparent that individuals do participate in different activities on a daily basis. It was also commented about one person that was “quite withdrawn when came to live at St Annes Rd” and now “blossomed a lot”. There was also documented evidence of other people gaining in confidence, particularly out in the community, helping to demonstrate that individuals are benefiting from recreational and leisure activities and are comfortable with community participation. In discussion with service users, it was identified that service users do have appropriate relationships with friends and contact with family members is encouraged and supported and it was observed that service users have contact details for relatives and friends, with birthday dates for relevant people in their files. As previously mentioned an advocacy agency has been approached in order to obtain an advocate for one of the service users, to provide impartial personal advice and help. This again helps to demonstrate that service users are supported to make informed decisions and choices about their lives. It was observed that a good rapport between the staff on duty and the service users was evident and that respect, privacy and dignity are demonstrated within the home. A healthy eating plan is still in operation and the service users were aware of this, for example, attending ‘weight watchers’ and some of the planned activities, involving exercise are also an indication that the home is committed to promoting healthy lifestyles for individuals. Menus were examined and found to be varied, wholesome and nutritious, with individuals getting involved in different aspects of meal preparation and cooking, depending on their abilities. St Annes Road East (85) DS0000009887.V303943.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. “Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service”. The home works in partnership with other agencies to ensure that service users’ health needs are fully assessed and addressed. Service users are empowered where possible to administer their own medication, thereby promoting independence and choice. EVIDENCE: Service users’ files contained, ‘Intimate and personal support plans’, with evidence that the intimate and personal support assessment for individuals had been reviewed in May 2006. There were medical profiles with other relevant information including: records of appointments and contact with GP, Chiropodists, Dentists, medical appointment forms and one of the service users’ files had very detailed guidance on how to get the person out of the building, in the event of an emergency, due to their mobility problem. The first inspection visit coincided with a visit from two nurses from the Learning Disability Team, who had come to the home to complete a health St Annes Road East (85) DS0000009887.V303943.R01.S.doc Version 5.2 Page 15 assessment for one of the service users after receiving a referral from the house manager. Unfortunately the time and date of the appointment had not been entered into the house diary or recorded in the service users’ file, consequently neither the member of staff on duty or the service user was aware that the assessment was to take place. This avoidable error was discussed with the house manager and assurances were given that any future appointments or meetings would be appropriately communicated, especially to the service user involved. One other persons’ file contained concise information and guidance regarding, some behavioural problems that this person may demonstrate and clear strategies and protocols were in place to be able to effectively manage such an occurrence in order to safeguard and protect the person and anyone else. The medicines were stored in a secure locked cupboard and were found to be stored appropriately, with records showing that they were also administered correctly, with only suitably trained staff eligible to administer medication. One service user with regular and diligent support is able to self medicate and this demonstrates that when possible there a commitment from the organisation to promote, enable and support individuals to be as independent as possible. St Annes Road East (85) DS0000009887.V303943.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. “Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service”. Thorough satisfactory policies and procedures regarding the protection of vulnerable people are in place, helping to ensure that service users are protected from harm. EVIDENCE: The organisation has a thorough and comprehensive complaints policy and procedures in place, with no complaints for St Annes Rd East having been received since the last inspection. In discussion with some of the staff members, there was a general understanding of the policy and the procedures. All staff receive protection of vulnerable adults training, with an annual refresher course and recently some staff attended a prevention of harm course. There was a thorough policy in place to deal with a suspicion or allegation of abuse. The staff who were spoken with were fully aware of the procedures to follow, if there was any suspicion or alleged abuse and would be confident in the process, highlighting that staff had been trained in the protection of vulnerable people. St Annes Road East (85) DS0000009887.V303943.R01.S.doc Version 5.2 Page 17 All members of staff have had Criminal Record Bureau Checks, (CRB) helping to safeguard that only appropriate people are employed to support and care for vulnerable adults. It was apparent that United Response is committed to providing good regular training, in order to ensure as much as possible that people in their care are protected and safeguarded from harm and abuse. St Annes Road East (85) DS0000009887.V303943.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 and 30. “Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service”. The home is comfortable, homely and generally clean, however the floor covering in the kitchen needs to be replaced, to help ensure that good health and safety standards are maintained. EVIDENCE: A full tour of the home was carried out and it was decorated to a satisfactory standard. The service users’ bedrooms were bright and pleasantly decorated, with their own identity and personal belongings. One person uses a wheelchair outside of the home and the chair is stored satisfactorily in the hallway The home was generally clean and hygienic with an outside laundry provided to help ensure that the risk of infection is managed and controlled, in order to promote a clean and safe environment for service users and staff. St Annes Road East (85) DS0000009887.V303943.R01.S.doc Version 5.2 Page 19 There was a fully equipped kitchen, which was generally clean and tidy, however the linoleum floor covering is in need of being replaced, it doesn’t fully fit and in places it was torn. The home is very spacious, with the lounge areas being well furnished and homely. The lock on the toilet door on the ground floor was seen to be in need of either being replaced or fixing, in order for individuals to be able to use the locking facility more easily. The premises outside were well maintained, with neat and tidy gardens to the front and rear of the property. There was a disused refrigerator at the back of the home and the manager was informed that this item should be removed. There was a ramp at the front of the building, which is an obvious asset for wheelchair users or anyone with mobility problems. As already mentioned the laundry is housed in a separate building at the rear of the property and it was found to well equipped. The house manager was made aware about the kitchen flooring and the lock on the toilet door needing attention. St Annes Road East (85) DS0000009887.V303943.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, 34 and 35. “Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service”. The staff team have the necessary skills and experience to provide a good standard of care to vulnerable people. The home has a thorough recruitment process, which gives the confidence that service users are protected and safeguarded as much as possible. The training provided is very good and helps to ensure that the service users are cared for and supported by well-trained staff. EVIDENCE: Staff files were examined and found to contain information with regards to the experience, skills and training that staff have received. Training included but was not limited to: the management of challenging behaviour, protection of vulnerable adults, equality and diversity, first aid and health and safety. All staff undergo an induction training period were mandatory training courses are taught. St Annes Road East (85) DS0000009887.V303943.R01.S.doc Version 5.2 Page 21 The ‘Additional support team’ (Social services’ department) will be providing some training in September with regard to the management of challenging behaviour called ‘Positive behavioural analysis’, helping to demonstrate that the provider is committed to accessing good, quality training to ensure that the correct support is given, in all aspects of care. Recently a team-building day was organised and it was described as “a great success” and another person said, “it was brilliant”. Over 80 of the staff team have obtained the National Vocation Qualification (NVQ) at level 2. This helps to give confidence that suitably qualified and skilful staff support service users. Staff members have varied experience in working with people from different cultures and faiths. In discussion with staff, there was an understanding and awareness of people’s cultural and religious needs. Service users’ care plans gave clear information of their needs and after speaking to individual service users, it was evident that their needs were being met. Members of staff were observed interacting with service users and they demonstrated that they were listening, interested and committed to the people that they were supporting. A thorough recruitment policy was in place with satisfactory procedures, which took into account the need to protect service users. Staff files contained evidence that Criminal Record Bureau (CRB) checks had been carried out and staff are only employed on the satisfactory completion of these checks and two reverences being obtained. This helps to ensure that service users are protected and safeguarded by having a robust recruitment selection process. St Annes Road East (85) DS0000009887.V303943.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): 37, 39 and 42. “Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service”. The management and organisation of the home has improved, which helps to give the assurance that people are receiving a good level of care and support. EVIDENCE: As mentioned in the previous inspection report, the registered manger is responsible for managing four care homes in the St Annes area. However, the person mostly responsible for the day to day running of St Annes Rd East is the house manager and she has many years of experience of working with people who have a learning disability and has been the house manger for the past two years. She is well qualified and is presently in the process of studying for the NVQ level 4, which she has nearly completed. St Annes Road East (85) DS0000009887.V303943.R01.S.doc Version 5.2 Page 23 The organisation has maintained ‘The investors in people award’ for a number of years, which is a quality assurance-monitoring organisation. United Response also have their own quality monitoring system and periodically questionnaires are sent to relatives, enquiring of their opinions regarding the standard of care being delivered to their relatives. Reviews for service users are held on a six monthly basis and team meetings are held on a 3 monthly basis and as already mentioned a team building day was recently organised which was described as a “great success”. In discussion with some staff members it was commented, “the manager is approachable and always available” and “since this manager took over, things have really improved” and one other said “we are now included in things, which we weren’t before”. In observation throughout the two visits it was apparent that a respect and appreciation was evident between the house manager and the staff team. Health and safety files were examined and almost everything was in order and up to date, including: water inspection checks, portable electric appliance testing, fire extinguishers, emergency lights and fire alarms. However, no gas or electric inspection certificates were available for examination. There was a signed form to say that they had been inspected, but it is necessary to have up to date certificates to verify that these inspections have been carried out. The organisation has been informed that the inspections of gas and electric installations have to be carried out by registered companies and correct inspection certificates have to be issued. It is essential that all health and safety checks be carried out, to help ensure that service users and staff are protected and safeguarded with regards to health and safety matters. St Annes Road East (85) DS0000009887.V303943.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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X St Annes Road East (85) DS0000009887.V303943.R01.S.doc Version 5.2 Page 25 NONE 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 YA24 Regulation 23 (2) (b) (d) (o) Requirement The kitchen flooring to be replaced. The toilet door lock to be fixed or replaced. The refrigerator to be removed and the grounds suitably maintained. Timescale for action 30/09/06 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. 2 Refer to Standard YA37 YA2 Good Practice Recommendations The registered manager should achieve qualifications at Level 4 NVQ in both management and care. Service users’ files to be better organised, with more detailed information, for example, individuals date of admission. St Annes Road East (85) DS0000009887.V303943.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Annes Road East (85) DS0000009887.V303943.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. 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