Inspection on 23/09/05 for St Edwards (6).

This inspection was carried out on 23rd September 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Edwards (6). 16/07/07

St Edwards (6). 04/07/06

St Edwards (6). 25/05/05

St Edwards (6). 22/11/04

St Edwards (6). 21/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 St Edwards (6) 6 St Edwards Close New Addington Croydon CR0 0EL Lead Inspector Peter Stanley Unannounced Inspection 23rd September 2005 9:30am 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 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 Stationary 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 Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Edwards (6) Address 6 St Edwards Close, New Addington, Croydon, Surrey, CR0 0EL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01689 800 960 01689 800 861 croydon@nas.org.uk National Autistic Society Mr Robert Torrance Care Home 12 Category(ies) of Learning Disability (12) registration, with number of places St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 25 May 2005 Brief Description of the Service: St Edwards is situated in a quiet close in New Addington near to local shops and trams. The National Autistic Society leases the building from Croydon Churches Housing Association. All service users have been identified as having an autistic disorder. The service provides residential care for twelve residents in two houses, which are separated by an attractive garden area. One of the houses is for male residents only, the other is shared between male and female service users. All residents have a single room; all contain a wash hand basin although some are not in use. This is due to the particular needs of the person occupying those rooms and has been agreed with the registration authority as being in their best interests. The furniture in some bedrooms has also been specially adapted where necessary. In addition to the bedrooms there is a communal lounge, dining room, a kitchen, toilets and bathroom in each house. Each house has its own staff team, with one waking member of staff allocated to each and one member of staff sleeping in. Residents attend Coney Hall Day Centre in West Wickham from Monday to Friday. This is housed in the same building as many of the National Autistic Society’s regional administrative functions such as personnel, and was seen during the course of this announced inspection. St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. St Edwards is a purpose-built home for adults who have autism or aspergers syndrome. There are two houses within the home with a gender divide, each accommodating six residents. Female residents are accommodated in The Willows while male residents are accommodated in The Conifers. The home had a very positive report for the last announced inspection, on 25 May 2005, which covered most of the care standards. This unannounced inspection was conducted over one day with the registered manager, Robert Torrance. This involved visiting the home and the NAS (National Autistic Society) Day Centre at Coney Hall where staff records are kept, and the NAS Transitions Day Centre in Croydon which provides day care for service users with Aspbergers Syndrome. A relatively few standards were inspected on this occasion, the inspection focussing primarily on service users experience of their day care; a number of health and safety issues, an adult protection concern, and issues arising from the last inspection were addressed with the registered manager. The inspector met a number of service users during the course of this inspection, the parent of a service user, and members of staff on duty (the deputy manager, and a senior care worker). The inspector also spoke to day care staff. The inspector was able to engage verbally with just one service user, other service users having generally very limited or no verbal communication. Through a process of non-verbal interaction and observation the inspector was able to ascertain that service users felt settled in their day care environment and that they feel well supported by staff in their day-today activity. As a result of this inspection there are six requirements (two of which are carried over from the previous inspection) and two recommendations. The inspector would like to thank the manager, residential and day care staff for their assistance and cooperation during this inspection. What the service does well: St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 6 The inspector has previously found St Edwards to be a pleasant, relaxed and well managed home, with a high level of management and staff commitment On this inspection, the inspector observed service users in their day care setting and found NAS residential and day care staff to be responsive to service users’ needs, and to be professional and caring in their interactions. Service users were observed to be settled and purposefully engaged in learning and recreational activities, and indicated a sense of well-being and satisfaction with their environment and the support provided. Service users have their health, personal and social care needs set out in an individual plan of care, and are fully involved in the care planning process. Service users are provided with opportunities for participating in a varied range of day care activities and for developing their interests and abilities. Service users are also assisted to develop daily living skills through guidance/support with participating in daily routines within the home. The home has an appropriate and well-publicised complaints policy and procedure in place. Clear information for raising complaints is made available in an appropriate format for service users. The home’s adult protection policies, procedures and practice evidence that service users are being protected from abuse and are living in a safe environment. The views and wishes of service users and their relatives are being ascertained, and taken into account, in the self-monitoring, review and development of the home. What has improved since the last inspection? The home is on track for meeting the target of 50 of care staff with a minimum of NVQ Level 2. The home has a rolling programme of adult protection training which is gradually ensuring that all staff undertake this. The home has appropriate recruitment policy and practices in place. These are now providing the required level of protection for service users. The internal audit of service users’ bedrooms has been completed and evidenced. St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 7 Policies and procedures are in place and in good order. All of the home’s policies and procedures have now been reviewed and are up-to-date. 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 Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 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 standard(s) EVIDENCE: This section not assessed. There have not been any new admissions. All standards were met at the last inspection. St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 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 standard(s) 6 Service users have their health, personal and social care needs set out in an individual plan of care, and are fully involved in the care planning process. One service user, who exhibits a pattern of inappropriate behaviour, requires a revised risk assessment and care plan. EVIDENCE: Standards 7, 8, 9 and 10 not assessed. All were met at the last inspection. The inspector examined a number of service users’ files. These detail a range of individualised health and social needs with guidelines on necessary interventions for each user. The home’s approach is to try and identify triggers and take preventative action if possible and use the least intrusive method of control if this is required. There is a detailed care plan and individual learning plan for each service user, together with individual risk assessments, a health check and medication profile. Service users’ care plans are reviewed on an annual basis, and provide information relating to users’ support needs and short term goals throughout the year. These are signed and dated. St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 11 There was one requirement from the last inspection. The reviews of two service users, which did not appear on the service users files at the last inspection, have now been evidenced. Review minutes of service users were up-to-date and on file. The inspector examined the file of a service user for whom there has been a recent concern involving inappropriate behaviour by the service user, and a subsequent allegation made against a staff member. While this has been fully addressed as part of an adult protection investigation, the home is developing a revised strategy and risk assessment with the sponsoring local authority. This is intended to spell out the risks, and actions required, to minimise and manage any further instances of inappropriate or challenging behaviour. The Care Plan, last reviewed on 13/4/05, will need to be further reviewed and amended once the revised risk assessment and specific actions required have been agreed. A copy of the revised risk assessment and care plan will need to be forwarded to the CSCI. A requirement applies. St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 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 standard(s) 11 and 12 Service users are provided with opportunities for participating in a varied range of day care activities and for developing their interests and abilities. Service users are also assisted to develop daily living skills through guidance/support with participating in daily routines within the home. EVIDENCE: St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 13 Standards 13 to 17 not assessed. Met at the last inspection. Documentation such as the ‘Welcome Pack’ sets out the aims of the home, which include providing individuals with opportunities for development. The large majority of service users regularly attend the NAS day centres, one of which, ‘Transitions’, in Croydon, is primarily for those who have higher functioning Aspergers Syndrome and Autism. The other day centre, which a larger group of service users from the home attend, provides specialist day care for service users with autism, and includes both residents from St Edwards and users living in the community. The day centres provide a structured programme of activities which is tailored according to the needs of each service user For this inspection, the inspector visited both day centres, where there were a number of service users from St Edwards. Whilst it was not possible to engage verbally with most of those present, the inspector was able to interact with some service users, and to observe their routines. Care staff from St Edward’s accompany and support service users to each of the two day centres where there are also trained day centre staff. The inspector looked at some of the day care records which staff maintain relating to the daily routines and progress of service users. These were wellmaintained and evidenced an ongoing record of each service user’s attendance, activities and development. Activity programmes are reviewed at six-monthly intervals with both service users and relatives being consulted regarding any changes, which they would like to see, introduced or altered. The Transitions Day Centre, based in West Croydon, offers a specialised day care service for service users with Aspbergers Syndrome. Care staff from the home accompany residents to the centre where they complement the input of specialised day care staff. The centre provides a varied range of activities which includes painting, drawing, writing, drama and computer use. The inspector was shown round by a service user who was able to explain, in considerable detail, the layout of the building and the nature of the environment and activities undertaken. There are a number of small rooms for differing recreational and developmental activities. Whilst it proved very difficult to engage most of those service users present, the inspector was able to observe individuals in this setting, and to evidence that they felt settled and supported. Staff were observed to work closely with service users in encouraging their participation and in assisting to develop their abilities and interests. As at Coney Hall, lunch, snacks and drinks are provided, pictorial symbols being used to denote the choices on offer. At Coney Hall Day Centre, activities include art, woodwork, drama, computer use, writing skills, and communication sessions. A sensory room is also available. The inspector met with staff and service users observed some of the St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 14 varied activities which are undertaken. Some of the more able service users were not present on the day, being engaged in outdoor activities such as horse riding. Those service users who were present had very restricted verbal communication but were able to indicate a sense of well-being with their environment. The inspector observed some structured activity, with writing and drawing, and the use of a soft play area for relaxation and therapy. Another service user was receiving one-to-one help with developing language skills through the use of visual prompts such as photos and pictures. Service users are assisted to develop daily living skills through participation in daily routines at the home. Staff spoken to demonstrated a caring attitude and an understanding of service users’ needs. Close working relationships with the day service staff enables service users to benefit from continuity of care and behavioural management. There are Behavioural Management guidelines for individual residents, with staff having access to specialist advice from psychiatrists and psychologists. St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 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 standard(s) 21 The ageing, and eventuality of a service user’s illness or death is treated appropriately, and with respect. Service users experiencing bereavement or loss could benefit from the development of staff skills and insights that training in this area could provide. EVIDENCE: Standards 18 to 20 not assessed. Met at the last inspection. The inspector discussed the issues of ageing and bereavement. The manager indicated that with two service users in their late fifties there was a growing realisation within the NAS of the need to plan ahead for their future care as older adults. The wishes of service users and their relatives concerning the eventuality of their death are recorded and placed on their files. The inspector discussed the need for staff to undertake training in the area of bereavement and loss and is including this as a recommendation. St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 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 standard(s) 22 and 23 The home has an appropriate and well-publicised complaints policy and procedure in place. Clear information for raising complaints is made available in an appropriate format for service users. The home’s adult protection policies, procedures and practice evidence that service users are being protected from abuse and are living in a safe environment. The home has a rolling programme of training to ensure that all staff undertake adult protection training. EVIDENCE: There have been no complaints since the last announced inspection. A record of complaints made about the operation of the home is appropriately maintained. This includes details of any investigation, its outcome, and action taken. All complaints are responded to within twenty-eight days after the date on which the complaint was made. Following a requirement at the last inspection, the right of the complainant to refer a complaint to the CSCI at any time has been included, together with contact details. The home is now logging compliments as well as complaints, two of which have been recorded since the last inspection. Since the last inspection there has been one adult protection referral. This involved a service user who had made an allegation of inappropriate touching by a care bank worker. The allegation has been fully investigated and followed up through the statutory adult protection procedures. As a result, the allegation been found to be baseless, and the care worker has been exonerated. The inspector discussed the ‘incident’ with the inspector and is satisfied that this was dealt with in an appropriate way. As mentioned in the St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 17 minutes of the third strategy meeting the investigation highlighted the need for very specific and detailed recording of any such incident by the staff member on duty at the time. The alleged incident was found to be associated with inappropriately sexualised behaviour presented by the service user, the feeling of his having been challenged about a specific instance of this having, it was found, been a causal link to the subsequent allegation. As a result of this a new risk assessment is being drawn up so as to clearly specify this area of risk and the actions required to manage this behaviour when it occurs. The home’s approach is to try and identify triggers and take preventative action if possible, and to use the least intrusive method of control when this is required. There have been no further concerns since this incident, and the inspector is satisfied that the service user is safe and well, and that the home has acted in a professional and appropriate manner in addressing this issue. The home has an Adult Protection procedure, which is in line with Croydon’s multi-agency vulnerable adult procedures. The home also has an appropriate whistle blowing procedure. Physical and verbal aggression by a service user is understood and dealt with appropriately, in accordance with the homes physical intervention policy. All staff have undertaken restraint and breakaway techniques training in accordance with Department of Health guidelines. The home has a rolling programme to ensure that all staff undertake adult protection training. The manager has completed Croydon’s Training for Trainers adult protection course, and is able to deliver this training to the home’s staff. 21 of the 23 staff have now attended. Two care workers have still to complete this training, and are due to attend the next scheduled one-day course in October 2005; a requirement from the last inspection applies, the time-scale for this expiring in October. St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 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 standard(s) 24 Generally, service users are evidenced to live in an environment, which is safe, well maintained and adapted for people with disabilities. However, there are three health and safety concerns identified, which place service users at potential risk. EVIDENCE: Standards 25 to 30 were not assessed. All were met at the last inspection. St. Edwards was purpose built for people with disabilities. The home is well laid out and meets the needs of the service users. The garden is well laid out and maintained. There is a ramp to the front door but no lift. In style it blends in well with the local community. The premises were inspected and found to be homely, comfortable and generally safe. Fittings, adaptations and equipment are of good quality, and domestic in scale. St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 19 The home was decorated to a reasonably high standard throughout and presents as being comfortable, bright and warm, and clean throughout. Relevant training in ensuring hygiene is provided for staff. There is a planned programme of maintenance for the redecoration of the home, four service users’ rooms being scheduled for redecoration. An audit of all service users’ bedrooms has been undertaken, so as to ensure that all are maintained to a good state of decoration and repair. This has now been evidenced, with a copy having been forwarded to the CSCI. The inspector inspected the premises and identified three health and safety concerns, for which requirements apply: Cleaning powder was found in an unlocked cupboard above the locked COSHH cupboard, where it should have been located. Extractor fans throughout both residents’ houses were badly clogged with dirt and must be cleaned. The nosing across the top stair of the staircase was loose and requires securing, while the stair itself was in a potentially dangerous state (loose and crumbly) and requiring repair. St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 and 34 Service users are evidenced to have their needs well met by an appropriately trained and qualified staff group. The home is on track for meeting the target of 50 of care staff with a minimum of NVQ Level 2. The home has appropriate recruitment policy and practices in place. These are now providing the required level of protection for service users. EVIDENCE: Standards 31, 33, 35 and 36 not assessed. Met at the last inspection. No new staff have been recruited since the last inspection. The home’s staffing levels comply with those agreed with the previous Registration Authority. Staff rotas confirm that the home has 3 staff on duty in each house at all times during the day. This gives a staffing ratio of 2:1. In addition to this several service users receive 1:1 support at key times during the day. Each house has 1 waking night staff and a sleep in member of staff is shared between the two houses. The home’s manager is on-call during weekdays from Monday to Friday, and covers alternate weekends in tandem with the deputy manager. There is also an on-call Out of Hours Service St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 21 provided within the organisation for providing cover for any emergencies that may arise. The inspector spoke to care staff during the inspection and ascertained that they feel well supported in their present roles and receive the necessary training with which to further their professional development and meet the needs of service users. There are two requirements from the previous inspection. The first relates to the need for the home to meet the target of 50 target of all care staff in the home qualified to a minimum of NVQ Level 2 by 2005. The manager confirmed that the home is currently on track for meeting this target. Currently, of 23 care staff, 1 staff member is qualified to NVQ Level 2, 5 to NVQ Level 3 and 1 (the deputy manager) to NVQ Level 4. A further 1 staff member is registered for study towards NVQ Level 2, and 10 care staff, registered for study towards NVQ Level 3. The second requirement related to the need for an up-to-date CRB (Criminal Records Bureau) certificate to be put in place to have been put in place for a recently recruited staff member. The inspector checked the staff file wich confirmed that this has been obtained. As no new members of staff have been recruited since the last inspection, no further checks were possible. Both the registered manager and administrator understand the current position with CRB checks and the inspector received assurances that no further new care staff will commence employment until the new CRB certificate has been obtained. St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 40 The views and wishes of service users and their relatives are being ascertained, and taken into account, in the self-monitoring, review and development of the home. Policies and procedures are in place and in good order. All of the home’s policies and procedures have now been reviewed. EVIDENCE: Standards 37, 38, 41, 42 and 43 not assessed. Met at the last inspection. The inspector’s was able to evidence the strong ethos in the home towards fully involving service users in decisions affecting their day to day lives and the running of the home. This was apparent in the detailed individual care and learning plans and in the feedback received from service users and relatives on this and previous inspections. The minutes of service user meetings indicated that service users views are regularly canvassed at weekly or two-weekly St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 23 meetings, with discussion of such topics as forthcoming choice of activities, service users’ wishes and needs regarding the upkeep of the home, their daily routines, and food choices for the week ahead. The home has a robust and innovative approach to Quality Assurance using an accepted tool ‘Accreditation for People with Autism.’ This includes an evaluation over a period of 2-3 days carried out by a panel of 4-5 people, which includes a layperson. The last inspection under the accredited scheme was in August 2005 and the home is due to have its accreditation renewed when the Accreditation Panel meets in October. There is also a Service Support Committee, which consists of the landlord, Housing Association, relatives, staff and a community representative. This committee also carries out unannounced visits at the home, reports of which are produced. There is active involvement by some parents and relatives in the support of St Edwards, and their views regarding the home are sought and taken into account. The inspector met the parents of a service user at the last inspection and received very positive feedback regarding the home. This indicated that the home provides a very homely and welcoming environment, and enables relatives to be fully involved and to maintain close contact with service users. There was a requirement from the last inspection relating to the need for all the home’s policies and procedures to be annually reviewed. The inspector examined the Home’s Policies and Procedures Manual and noted that these had been reviewed in June 2005. The inspector recommends that a Policies and Procedures checklist is included at the front of the manual, to include the date when each of these was last reviewed and the signature/position of the person undertaking the review. St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 3 3 x x x x x Standard No 31 32 33 34 35 36 Score x 2 x 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Edwards (6) Score x x x 3 Standard No 37 38 39 40 41 42 43 Score x x 3 3 x x x G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 25 Yes 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 Regulation 15(1) & (2) Requirement The home must review and put in place a revised risk assessment and care plan to meet the concerns presented by a service user with a specific pattern of inappropriate behaviour. A copy of these must be forwarded to the CSCI. The registered manager must ensure that all cleaning fluids and powders, and other substances which are potentially hazardous to the health and safety of service users, are secured in a locked COSHH cupboard. The nosing across the top stair of the staircase in The Conifers requires securing, while the stair itself requires repair. Extractor fans throughout both residents’ houses must be declogged and cleaned. The registered manager must ensure that all staff employed at the home receive adult protection training. The home must meet the target of 50 of all care staff to have achieved a minimum of NVQ Timescale for action 1 November 2005 2. YA24 13(4)a&c From date of inspection. 3. YA24 13(4)a&c Within 7 days of inspection. Within 28 days of inspection. 31 October 2005 31 December 2005 Page 26 4. YA24 13(4)a&c 5. YA23 13(6), 18(1)(a) & (c) 18(1)(a) & (c) 6. YA32 St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Level 2 by 2005. 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 YA21 YA40 Good Practice Recommendations The inspector recommends that staff undertake training in the area of bereavement and loss. The inspector recommends that a Policies and Procedures checklist is included at the front of the manual, to include the date when each of these was last reviewed and the signature/position of the person undertaking the review. St Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 27 Commission for Social Care Inspection 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Edwards (6) G53 S25839 StEdwards V228475 230905 stage4.doc Version 1.40 Page 28 - 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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