Inspection on 26/06/06 for St James House

This inspection was carried out on 26th June 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 James House 03/05/07

St James House 28/02/06

St James House 10/11/05

St James House 17/11/04

St James House 15/06/04

St James House 08/12/03

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 James` House Danes Road Rusholme Manchester M14 5JT Lead Inspector Sarah Oldham Key Unannounced Inspection 26th June 2006 10.30 St James` House DS0000021626.V301578.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 James` House DS0000021626.V301578.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 James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St James` House Address Danes Road Rusholme Manchester M14 5JT 0161 225 6999 0161 224 9355 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) Standwalk Limited Wendy Nield Care Home 14 Category(ies) of Learning disability (14) registration, with number of places St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. A maximum of 14 service users will be accommodated. The home will only provide a service to people whose primary need for care arises from a learning disability with associated challenging behaviour. Accommodation will be provided in three separate units. The home will not accommodate: (i) people who have a criminal conviction, (ii) those people whose risk assessment indicates that they are likely to pose a risk to the general public (iii) sexual Offenders, (iv) people with a history of sexualised behaviour, unless a full risk assessment has been carried out and it is clear that the behaviour is either situation specific or can be controlled in other ways A manager with qualifications, agreed as appropriate by the Commission for Social Care Inspection, will be employed to manage the day to day running of the home at all times. In the absence of the manager, day to day running of the home will be the responsibility of a senior member of staff who has substantial experience at a senior level and/or qualifications relating to care of people with a learning disability and associated challenging behaviour. Staffing levels must be commensurate with the needs of the services users and must be sufficient to allow for them to be escorted outside the building on a one:one or two:one basis, as per their assessment. Night care provision will consist of a member of staff on waking duty per unit. 28th February 2006 5. 6. 7. Date of last inspection Brief Description of the Service: St James House is a registered home providing 24-hour care and accommodation for 14 persons with a learning disability and associated challenging behaviours. The home is situated in the Rusholme area of South Manchester, close to local amenities and transport routes. The home is a converted church sited in a residential area within its own grounds. It is accessed directly from a residential street and has adequate parking and an extensive and wellmanaged garden. St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 5 The home is divided into three separate areas, offering a range of facilities to cater for people with varying levels of support needs. Bedroom accommodation is provided on the ground, first and second floors. The ground and second floor bedrooms are single with en-suite facilities and a self-contained flat. The first floor contains three self-contained flats and three single rooms. The building is fully accessible and there is lift access to all floors. There are a variety of communal areas on each floor including lounges, kitchens, laundry facilities, a well-equipped sensory room, and hydrotherapy pool and gym room. St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced site visit was made to the home as part of the inspection process, by an inspector on Tuesday 26 June 2006. The visit lasted five hours. The home was not told about the visit beforehand. To help write the report the home was asked to provide information to the Commission for Social Care Inspection (CSCI) in the form of a questionnaire. The report also includes other information, which is held on CSCI’s files on the home. During the visit the inspector spoke with members of staff and the residents. Further information was also gained by talking with Care Managers who commissioned services from the home. One requirement from the previous inspection was still outstanding although the home had taken steps to beginning to address this. The fees range according to individual needs and can be obtained from the service directly. What the service does well: The home provides a good quality service to individuals with complex needs. All residents have a comprehensive assessment to identify their individual needs to make sure the service is able to meet the prospective residents’ needs. The home admits individuals to the home on a planned basis and does not accept people in an emergency. The home puts in place a care plan with the residents’ their families, representatives and other professionals. The plan includes information about all parts of the daily living of the individual and is recorded in both written and pictorial form. The plan includes risk assessments and this is looked at on a regular basis as part of a review of the care plan. Consultation with residents is evident both individually and within a group setting. Care managers, who assess peoples’ needs, were spoken to and feel that the home provides a good standard of care and support to the residents. They also said that communication between the home and other professionals was maintained to ensure that the needs of the resident were met. The home actively promotes the health care of the individuals and all residents are registered with a GP. Medication is stored and administered appropriately with clear policies and procedures in place for the management of medication. St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 7 The equipment within the home supports individuals to maintain their independence and is suitable for people who use wheelchairs. Equipment to assist with personal care was provided following an assessment from an occupational therapist or a physiotherapist. All residents have their own bedrooms that are personalised and furnished appropriately. Residents’ who required additional space due to their own specific behavioural needs were able to have areas with their own designated lounge area to enable them to have privacy and space. One resident spoken to said, “ I really like my room. I have my television and music and I like to keep it nice and tidy”. Other facilities within the home included a sensory room that provided sensory stimulation for the residents that included different lighting, music and soft seating areas. The manager said that this room was a valuable facility that all residents benefited from. The home worked closely with other professionals to ensure that the service that they provided met the changing needs of the resident. Care managers spoken to said, “ the service is responsive to the needs of the individual”. 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 James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 The quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. All prospective residents’ have an assessment of their need undertaken and are able to visit and spend time at the home to ensure that the service is able to meet their needs. EVIDENCE: All the residents at the home were referred via Care Management and all had a care manager who had undertaken an assessment of need prior to the referral being made to the home. The home requested a copy of the care plan and also undertook their own independent assessment to ensure that the home could meet the needs of the individual. The home further developed the care plan. This was done in conjunction with the resident and other health and social care professionals to ensure that the resident had an individualised care plan. Prior to admission to the home the prospective resident is supported, wherever possible, to have a series of introductory visits to the home to meet staff and other residents. This may also include an overnight visit. Where a visit did not occur prior to admission this was due to being risk assessed for that individual that they would find the visit disruptive to their daily living. The manager from the home however, visited the individual and provided information about the home. This was written in plain English and also in pictorial format. St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 10 All admissions to the home are on a planned basis, the home does not admit any emergency placements. All admissions to the home were on a trial basis and offered a three month trial period of residence with a review held at the end of this period to ensure that the resident wished to stay and that the home met their needs. St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 The quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. All residents at the home have an individual care plan that supports them to achieve their personal goals taking into account appropriate risks as part of their daily living. EVIDENCE: Each person living at the home has a care plan that has been further developed from information received from the care manager and health care assessments. The service also undertook an assessment of the individuals need. Three care plans were viewed as part of inspection process. The care plans seen were written using pictorial information to enable the resident to be fully involved. The plan outlines all aspects of daily living and then each task of the plan was identified individually to ensure that there is clear guidance and communication to the staff supporting the individual. There was evidence that other health care professionals were involved in holistic planning and delivering of the individual care. Residents were supported to contribute to their plan of care to ensure that their views relating to their care needs were acted upon. St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 12 Residents had the opportunity to meet on a regular basis to discuss any issues about the home that they had. This opportunity was not taken up by all of the residents. The manager said that one of the residents attended all the meetings and that prior to the meeting speaks with the other residents to gain their views to take to the meetings. Copies of the minutes of the meetings were being maintained. Relatives and advocates of the residents’ were also welcome to attend the meetings. Care managers spoken to as part of the inspection process felt that the home supported and promoted the residents’ views and wishes by using a number of communication aids and resources. Details relating to advocacy services were available, although at the time of the visit to the home none of the residents were using the service. Records of decisions made by residents were maintained on their individual file. A copy of the file was held in the main office in addition to this each resident had their own care file within their room. As part of the care planning process residents are supported to take risks, these risks are documented clearly in their individual care file with risk management strategies in place. St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, & 17 The quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents are supported to access the local community and take part in activities both within the home and externally. Contact with family, friends and visitors is actively encouraged. Residents are involved with the planning of meals and a balanced diet was provided. EVIDENCE: Many of the residents at the home have complex needs and require a high level of staff support to enable them to participate in activities within the community. The manager said that residents at the home had the opportunity wherever possible to attend further education courses. At the time of the visit to the home there were no residents attending further education or vocational training although there was evidence that some residents had done so previously. The manager said that if it was part of an individuals care plan or something that they wished to do, staff would support the individual with this. St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 14 Residents were able to take part in a number of activities either on a 1 to 1 basis or within a group. The manager said that residents were supported to access the local community. One resident spoken to said, “ I like going shopping and enjoy going out”. The manager said that throughout the year several outings are arranged for the residents to places that they liked to go. Annual holidays were available however, some residents preferred to go out on day trips rather than on a weeks holiday. A number of residents have personal friends who visit them in the home. Family and friends are made to feel welcome. Family members who wish to continue providing ongoing support are able to do so and the staff work closely with family members to ensure that this was possible. Care managers spoken to said that residents were supported well by staff to pursue any activities that they wished to take part in and that the home worked in conjunction with family members to ensure that they were kept informed of their relatives care plan and activities that they took part in. The home provided a healthy and balanced diet. Menus were devised following consultation with the residents. The cultural requirements of the residents were respected and meal preparation took into account different cultural and dietary needs. One resident said, “ I really enjoy the food here”. Staff were observed to assist one resident prepare his own meal. St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 The quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents at the home receive the support that they require in an appropriate manner and are treated with dignity and respect by the staff. Their health care needs are assessed on a regular basis and any changes to condition or need recorded on their care plan. Risk assessments regarding managing medication are undertaken in conjunction with health care professionals and care managers. EVIDENCE: Residents were supported with their personal care needs in a sensitive and flexible manner. The manager said that staff are aware of how residents communicated their needs. This was recorded in the care plan and also with discussion with family and care managers. The times that residents liked to get up and go to bed were recorded in the care plans along with their routine that they liked to follow and the level of guidance and support required. This ensured that all staff were aware of and delivered the appropriate support to meet the residents’ needs. Any changes in residents needs were clearly recorded on the care plan. One resident said “ staff help me when I have a shower but I can manage mostly on my own but it is nice to have some help”. St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 16 Equipment was available to support the residents with their personal care needs. This equipment was supplied following an assessment from an occupational therapist or other professional trained to do so. All residents were registered with a GP and were supported to access health care professionals to support their health care. Reviews of resident’s healthcare needs were undertaken on a regular basis to ensure that they received the appropriate treatment and support. Care managers spoken to said that the health care needs of the residents at the home were given a high priority Systems were in place for the receipt, recording, administration, storage and return of medication. A ‘Drug Analysis File containing details of medication currently used and the side effects to be aware of for each resident had been compiled by the manager to ensure that staff had an understanding of the medication that they administered. One resident was self-medicating and written confirmation from their GP to state that the resident was capable of doing so within a risk management framework. This resident was supported by staff in the home to check their medication at the end of each month and to place a ‘re-order’ with the GP. Staff with the responsibility for the administration of medication had received training. A list of sample signatures of the staff that administered medication was maintained to ensure that there was a clear audit trail for the administration of medication. Medication Administration Record (MAR) sheets appeared to be signed appropriately with no gaps apparent. The recommendation made at the previous inspection for a photograph that each resident be placed on the MAR file for staff to be further supported and enabled to clearly identify each resident had been undertaken. St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents and their family/friends were aware of how and to whom to go to make a complaint. Staff were aware of the home’s complaints procedure and had received training with regards the Protection of Vulnerable Adults. EVIDENCE: The home had a clear complaint policy and procedure in place that detailed timescales and response time. The complaint procedure is also made available to relatives and supporters of the resident. The home maintained a copy of any complaints made and the action taken to address the complaint. All residents had been given a copy of the complaints procedure and a copy was kept on their file in their room. One resident spoken to said that if they were unhappy with anything or wanted to make a complaint said, “ I can always talk to staff here if there was something that I didn’t like”. The home had clear policies and procedures in place regarding the Protection of Vulnerable Adults. Staff had undertaken Protection of Vulnerable Adults training to ensure that they were able to identify protection issues and were aware on the procedure to follow to ensure the safety and well being of the resident. St James` House DS0000021626.V301578.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, 25, 26, 28 & 30 The quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. The communal areas of the home are clean, comfortable, well maintained and provide a range of recreational facilities for the residents. EVIDENCE: The home is a converted church sited in a residential area within its own grounds. The grounds of the home are large and well maintained with adequate parking facilities. There is an enclosed sensory garden in addition to the lawn areas. On the day of the site visit residents were enjoying having their lunch outside in a shaded area of the grounds. The accommodation of the home is on three levels with bedrooms on all levels. In addition to the bedroom areas, there are communal lounges, kitchen, gym, sensory room and hydrotherapy pool. At the time of the visit to the home the floor to the hydrotherapy room was being replaced. The owner of the home said that it was envisaged that this would be completed by the end of September. Due to the challenging behaviour of some of the residents the home had a continual maintenance programme in place. Details of maintenance undertaken St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 19 was viewed and demonstrated that repairs and any refurbishment to the home were undertaken regularly. Risk assessments regarding the home were undertaken and updated on a regular basis. The manager said that she regularly toured the building to ensure that the fabric and contents of the building were safe, homely and comfortable. At the previous inspection a requirement to replace carpets to the upstairs corridor had been undertaken. Three residents showed the inspector their rooms. One resident said, “ I really like my room. I have my television and music and I like to keep it nice and tidy”. All rooms viewed had been personalised by the resident with the support of staff. The kitchens and laundry facilities were appropriate for the number of residents at the home. These facilities were accessible for the residents who were supported by staff to use them. St James` House DS0000021626.V301578.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 & 35 The quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. The home’s training policies and procedures were in place and provided details to support the employment of well-trained staff. Recruitment policies and procedures had been reviewed following a number of staff being employed that was later found to have false documentation. EVIDENCE: At the time of the visit to the home the manager was using agency staff in addition to the regular staff team. This was due to a number of staff at the home leaving following an investigation by immigration regarding people using forged documentation. The manager said that relevant checks had been undertaken but that the status of the documentation had not been identified at the time. Following discussions with the Immigration Officials the home had placed additional procedures in place to verify that peoples’ identification is genuine. The manager said that all agency staff were given a ‘mini induction’ to the home prior to the commencement of their shift and were supported by a regular member of staff. A selection of staff files were viewed and found to contain completed application forms, evidence of qualifications and previous work experience. The manager said that two references were requested including one from a St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 21 previous employer to support the application. One file viewed contained only one reference. The manager said that she had seen another reference for this member of staff although it was not evidenced at the time of the visit. The need for appropriate references and information regarding staff being placed on file was discussed with the manager. The manager was very clear about the benefit of training for staff. She felt that it was important to ensure that staff had the skills and knowledge to support the residents to be as independent as possible. To provide staff with the necessary skills the home had a training programme in place for all staff. This was reviewed and updated on a regular basis. All staff completed an induction programme when first employed to ensure that they are aware and understood the aims and objectives of the home. Ongoing training included the Protection of Vulnerable Adults, First Aid, Food and Hygiene, Moving and Handling, Medication Administration and NVQ level 2. In addition to this, specific training relating to epilepsy and autism was planned to take place in July 2006. All staff had an individual training programme. This identified when refresher training for staff was required. The manager said that training was discussed during supervision and records maintained regarding training requested and training undertaken. Members of staff spoken to were able to demonstrate a good understanding of the complex needs of the residents. Staff spoken to felt that the training they had received increased their skills and knowledge to enable them to support the residents’ needs. Training regarding de-escalation techniques was also considered important by staff. The home was very clear that it did not use any form of restraint on residents. Staff were aware of this and found the de-escalation techniques used benefited the residents health and welfare needs better as it reduced any form of conflict. St James` House DS0000021626.V301578.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 & 42 The quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. The management role and responsibilities were clear with staff and residents being consulted about the running of the home. Staff received supervision and support to undertake their role and the practices within the home in general supported and safeguarded the health, safety and welfare of the people who use the service. EVIDENCE: The manager of the home has a number of years experience and has had the relevant training to update her skills and knowledge. She was continuing to work towards completing the Registered Managers Award. The manager is responsible along with the quality service manager for the review and updates of the policies and procedures of the home. The quality manager has the responsibility for monitoring and appraising the service delivery. Views are obtained from staff, residents, relatives and people St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 23 who commission the service to ensure that the service continues to meet the needs of the residents. The quality assurance manager presented information as evidence to the commission stating that the home complied with all health and safety requirements. St James` House DS0000021626.V301578.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 3 3 X 4 3 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 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X 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 X 12 3 13 3 14 3 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 3 X St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 25 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 YA34 Regulation 18 Requirement The home must ensure that all recruitment and selection procedures are completed in accordance with their recruitment and selection policy to safeguard the residents at the home. Timescale for action 30/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA34 Good Practice Recommendations It is recommended that agency staff induction is formalised and a record maintained of the induction undertaken. St James` House DS0000021626.V301578.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 James` House DS0000021626.V301578.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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