Inspection on 23/05/07 for St Marys Gate (25)

This inspection was carried out on 23rd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Marys Gate (25) 10/01/06

St Marys Gate (25) 25/08/05

St Marys Gate (25) 23/09/04

St Marys Gate (25) 27/04/04

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 Marys Gate (25) 25 St Marys Gate Euxton Chorley Lancashire PR7 6AH Lead Inspector Phil McConnell Unannounced Inspection 23rd May 2007 09:30 St Marys Gate (25) DS0000005938.V330877.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 Marys Gate (25) DS0000005938.V330877.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 Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marys Gate (25) Address 25 St Marys Gate Euxton Chorley Lancashire PR7 6AH 01257 241899 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) Link-Ability Charity Ltd Mrs Karen Whittle Care Home 4 Category(ies) of Learning disability (4) registration, with number of places St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Within the overall total of 4 a maximum of 3 service users requiring personal care who fall into the category of LD. Within the overall total of 4 a maximum of 1 service user requiring nursing care who falls into the category of LD. The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 10th January 2006 4. Date of last inspection Brief Description of the Service: St Marys Gate is registered to accommodate four service users with a learning disability. The home is one of a number of properties operated by Link-Ability, which is a non-profit making Voluntary Organisation. Link-Ability provides a service for both adults and children who in addition to having a learning disability also have additional complex health and/or behavioural difficulties. It is the aim of the Organisation to provide a tailor made package of care for each service user. In pursuing this aim there is close collaboration between Link-Ability and the service users parents/relatives. St Marys Gate is a purpose built bungalow situated in the village of Euxton. There is a range of local amenities, and those which are accessed further away in the Chorley district. The home is well suited to the needs of the service users, with facilities and equipment having been installed to meet their individual care needs. These are regularly reviewed to ensure they remain appropriate. All clients have their own bedrooms and these have been decorated and furnished to reflect the individual tastes, preferences and interests. There is a communal lounge and dining room, kitchen, laundry and guest bedroom, which serves as the staff sleeping facility and office. There are gardens on either side of the home, one of which provides an enclosed and private area. The front of the home faces onto a courtyard, which is shared with neighbours. The present rate of charging is between £1,315 and £1,990. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Various information was gathered in order to assess the key standards that are identified in the National Minimum Standards for Care Homes for Younger Adults, including: the pre inspection questionnaire, (completed by the registered manager) an unannounced inspection visit to the service on the 23rd of May 2007, which lasted approximately 7 hrs. There were 4 relatives questionnaires and 1 service user questionnaire returned to the Commission for Social Care Inspection (CSCI). The feedback from the questionnaires was generally very positive. The registered manager was available throughout the inspection visit. During the visit to the home all of the 4 service users’ files were examined and all relevant documentation was in place. There was the opportunity to observe the care provided to the service users and the interaction between them and the staff. Four staff files were also examined (at the main office), including the last person to be employed at St Mary’s Gate, with all documentation being found correct. Throughout the visit there was the opportunity to have conversations with other staff members. Some information was also obtained from the service users’ social worker, via telephone. The home’s policies, procedures and all other documentation including health and safety files and certificates were examined. (See management section). A full tour of the home was also carried out. (See environment section). What the service does well: The training provided is excellent. This helps give the assurance that people are supported by a well-trained and skilled staff team. The level of personal and health care provided is excellent. The home offers an excellent environment, which is clean, comfortable, welcoming and safe. Community participation and community presence are actively promoted and it is evident that there are valued links with the local community. People are empowered and enabled to live as independently as possible. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 6 There appears to be a really good ‘team spirit’ in the home, with the staff team demonstrating commitment, flexibility and contentment with their work. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Marys Gate (25) DS0000005938.V330877.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 Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good pre admission assessment process is in place, helping to ensure that a persons’ assessed needs will be appropriately met. EVIDENCE: A pre admissions policy and procedure were examined and found to be satisfactory. The four service users’ files were examined and they all contained individual and relevant assessment documentation including: admission assessments, care plans and up to date daily record sheets. Although there have been no new admissions since the last inspection, in discussion with the registered manager, it was clear that the process for pre admission assessment is clearly known and there is confidence that this would be correctly and professionally carried out. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 9 It was written in one of the service users comment cards, “we looked around the house before hand and I was able to move (with friends) as soon as the bungalow was available and I chose all the paint and furnishings for my room”. During the inspection visit, other documentation was observed that evidently showed that thorough assessments had taken place, in order to determine a person’s care needs and that Link Ability could meet their needs. The social worker for the people living at St Mary’s Gate said, “I have recently held annual reviews for all of the people and Link Ability invite everyone to the reviews including: relatives and day centre staff” and “if there are any issues between reviews, then they contact me”. Relevant and appropriate risk assessments were drawn up along with an in depth care plan, which are used to help ensure that the persons assessed needs are being appropriately met. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ care plans are detailed with sufficient information, helping to ensure that the best possible care is given to vulnerable people and people are empowered in various appropriate ways to make and take decisions in their daily lives. EVIDENCE: The service users’ files contained concise, detailed informative care plans, which are reviewed at least on a six monthly basis with the involvement of the individual service users’ relative or representative. There are daily checklists for each person and it was apparent that these checks are thoroughly carried out. This helps to ensure that peoples’ care needs are satisfactorily provided and any changing needs are quickly identified. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 11 There was evidence that person centred plans (PCP’S) are going to be implemented and in conversation with the social worker, she said, “during the recent reviews, there was discussion about PCP’S and relatives, staff and day centre staff were informed that these plans will be central to peoples’ future care”. The emphasis for person centred plans, is to gather as much information as possible from anyone who has any contact with the person, in order to clearly identify their dreams, aspirations and needs, so that people can reach their full potential. 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. It was also apparent that the staff are fully aware of the goals and aspirations for each person. One person had written in a comment card, “All the staff are used to my way of communicating and have even picked up things that my parents have missed” (Peoples comments had been written by their relatives) and another person wrote, “Link Ability are a very open service and always include parents and clients in any decisions about the care”. There were individual risk assessments in service users’ files, with specific information and guidance, in order to promote and encourage independence. Members of staff were observed communicating with service users in a respectful, relaxed, and dignified way and the service users were responding in a positive way, helping to demonstrate that service users and their families have the assurance and confidence that they are treated with respect and dignity. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are positively supported in participating in meaningful and appropriate activities, in order to provide stimulation, motivation and promote community presence and inclusion. EVIDENCE: As previously mentioned the service users’ have detailed and concise care plans, which give clear guidance and information about the various activities that individuals are involved in. During the inspection visit it was evident that people were individually involved in different activities and pursuits. People have the opportunity to access many different activities including: swimming, sensory room at the gateway club, St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 13 trampoline at the local college, and music workshop at the Catholic caring services, helping to demonstrate that people are encouraged and empowered to participate within the community. Some of the service users regularly attend a day centre and it was stated that good relationships exist between the centres and the home. Every week there are planned activities, “even if the weather is bad, we always go somewhere”. Good relationships also exist with the neighbours and it was said that, “when the garden was being done, the neighbours invited the service users to sit in their garden” and “when we are having a party or a get together, we invite the neighbours and they always come”. It was evident that community participation and community presence is positively and actively promoted. Throughout the day people were coming and going accessing different activities and it was apparent that these were regular and normal pursuits, with people obviously enjoying the trips out and the activities. In the home there was also evidence of recreational and leisure activities being available including, foot massage/spas, facials, and nail painting, “All to do with pampering and relaxation” and “when there is any football on the TV we all gather in the lounge, everyone loves it”. People are given full support in all activities; with daily communication records being maintained, which are regularly reviewed. It was clear that staff support individuals in the varied activities they have, to gain as much experience as possible. Thereby enabling people to maximise their independence, whilst also initiating self worth and wellbeing. It was evident that the service users have regular weekly visits from different family members and individuals are regularly supported to visit their relatives in their homes. In discussion with staff members and examination of records, it was apparent that much thought and planning goes into food menus. Where a person is fed through percutaneous endoscopy gastronomy (PEG) tube, concise records are kept. During the mid-day meal one service user was observed being supported in a calm, unrushed and relaxed manner. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. It is evident that peoples’ health and care needs are satisfactorily provided, with people being enabled and empowered to communicate their choices and wishes. EVIDENCE: The four service users’ files were well organised with individual ‘treatment plans’, covering: physical ability, mobility, medical history, and pattern of living, with health action plans in place for each person. There were ‘static files’ and ‘daily working’ files. Some of the comments from staff were, “she is not a morning person” and “she has a lovely sense of humour”. Helping to show that staff are fully aware of peoples’ needs, temperament and character. This helps them to support and care for people in an informative and knowledgeable manner. The files also included detailed personal information, such as N0K and telephone numbers in the event of an emergency. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 15 It was clear from the records seen, that peoples’ health care is very closely monitored, for example all of the service users have epilepsy and full and thorough descriptions were given of the different levels and severity of seizures that people could experience. There was also a list of possible reasons/triggers of why the person may be having a seizure. There was evidence that people have a close link with a nurse for people with epilepsy and people also have good and regular contact with GP’s, district nurses and occupational therapists. One relative wrote, “the staff work well with the day service by sharing of information, so everyone knows what is going on, especially concerning health issues”. During the inspection visit it appeared that one person was having a seizure and the staff responded immediately with sensitivity and expertise, reassuring and comforting the person. There were daily communication sheets, which were informative and up to date, in order to assist the carers in meeting the service users’ daily needs. Medication procedures and records were examined and found to be satisfactory, with all staff being appropriately trained in the storage, administration and recording of medicines. A good practice is in place whereby two members of staff sign for administered medication. This also helps to demonstrate that people are safeguarded and protected as much as possible. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory policies and procedures are in place, helping to protect people from abuse and harm. EVIDENCE: The policy and procedures were examined and found to be thorough and concise, with relevant addresses and telephone numbers for Social Services and for CSCI (commission for social care inspection). All staff have received ‘The Protection of Vulnerable Adults’ training. In speaking to staff they all had a full understanding of the importance of the protection of vulnerable people and were able to demonstrate how they would identify any potential abuse. People were also familiar with the organisations ‘whistle blowing’ policy. On person said, “I have had POVA training and I am fully aware of the procedures to follow, if I suspected any kind of abuse”. One complaint had been made to the organisation since the last inspection visit and this had been quickly dealt with. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe, clean and hygienic, providing a very pleasant environment for people who live and work there. EVIDENCE: The home provides ground floor accommodation in a building designed to meet the needs of the people who live there. A tour of the home was carried out and it was found to be clean, well decorated, comfortable and homely. During the inspection visit, two cleaners employed by the organisation were cleaning the home. (See staffing section). The lounge was in the process of being redecorated, although the present standard of décor was adequate. The laundry facilities and utility room are sufficient to meet the needs of the people who presently live at the home and there is a fully equipped modern kitchen. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 18 Peoples’ bedrooms contained evidence of individuality, with their own possessions and different items of interest or activity on display. Throughout the home there were different items of sensory apparatus strategically placed, in order to provide stimulation. The bedrooms and the bathrooms contained ceiling hoists. This is to assist with the management of moving and handling. Because of the recurring problem with damp, the shower/wet room is in need of some attention. The manager gave an assurance that this was in the process of being addressed. There is a bedroom provided for staff when they are on ‘sleep in’ duty. Some comments received form relatives were, “it is a safe environment for our sister to live in” and “the house is always clean and tidy”. The outside garden has been landscaped to an excellent standard, with wheelchair level flowerbeds, water features, wind chimes, different types of gravel and different types of herbs. These are all planned to increase sensory awareness. It is also planned to purchase a swing, which would be suitable for people who have complex disabilities. Generally the home is of a very good standard. It is safe, comfortable, clean, well decorated, bright and cheerful. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. People are supported and cared for by, well-trained, skilled and dedicated staff, helping to give service users and relatives the confidence and assurance that people are safeguarded and protected. EVIDENCE: Five of the staff files were examined and they contained all of the required documentation to meet the standard. These included, application forms, references, induction training, supervision notes and evidence of appropriate and relevant training that had been received. As well as the induction training, other relevant training has been provided, including, aspergers/autism awareness (autism spectrum disorder), LDAF (learning disability awareness framework) provided by Consortium training, visual awareness course, PEG training and safe swallowing training (provided by speech and language therapists. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 20 In discussion with the service users’ social worker, it was commented, “Link Ability commissioned a person, who has an expertise in working with people who have autism, communication and behavioural problems” and “this training/input has made a considerable and positive difference to the people living at St Mary’s Gate”. “Link Ability provide excellent training and if they can’t provide it in house, then they access it from elsewhere”. A thorough recruitment policy was in place with satisfactory procedures, which took into account the need to protect service users. There was evidence that Criminal Record Bureau (CRB) checks had been carried out and staff are only employed on the satisfactory completion of these checks. This helps to ensure that service users are protected and safeguarded by having a robust recruitment selection process. However during the inspection visit it came to light that the cleaners employed by the organisation hadn’t undergone a CRB check. This oversight has since been rectified, with clear checks having now been received by Link Ability. Some comments from the staff regarding training were, “the organisation is brilliant for training” “I have just completed my NVQ 3 in 8 months” and “ we are always being offered training, I have just started Person Centred Planning training (PCP)”. People were very complimentary regarding the quantity and quality of the training they had received and the examination of the training programme and matrix confirmed this. Some of the comments from relatives were, “the staff provide an excellent care service above and beyond what I could provide to my relative” and “the staff are well trained, caring and always happy in their work”. The staff on duty during the inspection visit demonstrated that they were well trained and more than adequately skilled to meet the service users’ needs. The support and care that was provided was calm and unhurried, helping again to show that the staff were committed to the people that they supported and cared for. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well run and organised with clear structures in place, which help to ensure that vulnerable people are protected and safeguarded as much as possible. EVIDENCE: The registered manager at St Mary’s Gate has over 17 years experience in care work and is also a qualified nurse. She has achieved level three in the national vocational qualification (NVQ), she is an NVQ assessor and has also acquired the registered managers award (RMA). St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 22 The manager plans, in the near future, to commence studying for her ‘return to practice’ (nursing) “in order to clinically supervise the nurses and provide support in the event of emergencies”. In discussion with some of the staff team it was apparent that good relationships exist between the manager and staff, one person said, “the manager is really down to earth, you can go to her with anything” and some relatives wrote, “the house is really well run and always involve parents and clients in all decisions, whether they will affect us or not” “I think the service is exceptional” and “I am unsure what could be done to improve the care”. The manager said, “We have a really good staff team, who are committed and dedicated”. The organisation has maintained the Investors in People Award, (a quality assurance monitoring organisation) demonstrating that there is a commitment from the organisation to have its quality of care assessed both internally and externally. The organisation also carries out their own self-monitoring quality assurance checks. All of the homes policies relating to health and safety were inspected and were found to be up to date, with review dates in place, helping to show that the health and safety of all who live and work at St Mary’s Gate is taken seriously. Inspection certificates, including; electrical inspection, portable appliance testing certificate (PAT), gas inspection, electric bed service checks, fridge and freezer (daily temperature charts kept), certificates for all of the hoists and an inspection certificate for legionella (water). There was documented evidence of fire alarm and fire drills being completed on a regular basis. This all helps to ensure that service users and staff are protected and safeguarded with regards to health and safety matters. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 2 35 4 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 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 3 X X 4 X St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23(2)(b) Requirement The premises must be kept in a good state of repair.(Shower/wet room) Timescale for action 31/08/07 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 OP29 Good Practice Recommendations All staff working at the home need to obtain criminal record bureau checks (CRB).See staffing section. St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Marys Gate (25) DS0000005938.V330877.R01.S.doc Version 5.2 Page 26 - 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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