Inspection on 20/07/07 for Stairways

This inspection was carried out on 20th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stairways 19/07/06

Stairways 08/11/05

Stairways 24/05/05

Stairways 23/11/04

Stairways 21/07/04

Stairways 12/12/03

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Stairways 19 Douglas Road Harpenden Hertfordshire AL5 2EN Lead Inspector Claire Farrier Unannounced Inspection 20th July 2007 10:00 Stairways DS0000019550.V346792.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 Stairways DS0000019550.V346792.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. Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stairways Address 19 Douglas Road Harpenden Hertfordshire AL5 2EN 01582 460 055 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) Harpenden Mencap Society Darren Lelliott Care Home 17 Category(ies) of Learning disability (17), Physical disability (17) registration, with number of places Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home may accommodate children and adults with learning disability or physical disability (when associated with learning disability). 19th July 2006 Date of last inspection Brief Description of the Service: Stairways is a care home for thirteen people with a learning disability, who may also have an associated physical disability. It is owned and managed by Harpenden Mencap, which is a voluntary organisation. The home is a large Edwardian house in Harpenden, divided into three selfcontained flats, each with kitchen, lounge, toilet, bathroom and bedrooms. Flat 1 accommodates up to five people with moderate to severe learning disability and physical disabilities; flat 2 accommodates up to 4 service people with severe learning disability who may display behavioural difficulties and flat 4 accommodates up to four people with a learning disability. There are spacious grounds surrounding the house and car parking for several vehicles at the front. The house is near Harpenden shops and other community amenities and public transport routes to St Albans and Luton are accessible. A separate short term care unit provides respite care for four children with learning disabilities. The regulation of children’s services is now the responsibility of Ofsted, and the service has applied to Ofsted for registration. The Statement of Purpose and Service Users Guide provide information about the home for referring social workers and prospective residents. The current charges range from £740.98 to £1473.74 per week. Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We spent one afternoon at Stairways, and the people who live there and work there did not know that we were coming. The focus of the inspection was to assess all the key standards. Some additional standards were also assessed. We talked to as many of the people who live in the home, as we were able to. We also talked to some of the staff, and to the home’s manager and the director of Harpenden Mencap. In one flat two people showed the inspector around. We talked to the home’s manager about what we had seen during the inspection. The manager sent some information (the Annual Quality Assurance Assessment, or AQAA) about the home to CSCI before the inspection, and his assessment of what the service does in each area. Evidence from the AQAA has been included in this report. What the service does well: The Annual Quality Assurance Assessment (AQAA) states: “We know that as a service we give excellent value for money. This is because we provide a service that is much more than purely residential. We encourage residents to have in place a life that promotes diversity and therefore this means that the input, organisation and staffing ratios is high.” The ethos of Stairways is that each person’s views are valued, and they are actively involved in the running of the home. The information in care plans, observation of the staff and residents, and discussions with staff and residents, all confirmed that everyone is encouraged and supported to make their views and wishes known, and to make decisions about their lives in the home. The inspector asked the people they spoke to how many stars they would give the home. Most people gave the home a maximum three stars, and one gave six, as an expression of how highly they rate the quality of their life in the home. There is a stable staff team in the home, and the training programme makes sure that they have the necessary skills to meet people’s needs. Most of the care staff have NVQ qualifications. The staff spoken to were enthusiastic about their work, and said that a good quality of training is provided for them. We saw that the staff have a good relationship with the people who live in the home. We thought that the staff look after people’s health care needs very well. The management have looked ahead to make sure that the service meets the changing needs of the people in the home. The AQAA stated that the managers lead by example, and this was seen during the inspection. Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stairways DS0000019550.V346792.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 Stairways DS0000019550.V346792.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 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has sufficient information on residents’ needs and access to appropriate services to enable their needs to be met. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) provided sufficient information so that we could assess the outcomes of these standards. Everyone who lives at Stairways has been there for many years, and the last admission was in 1998. The home’s policy on admission clearly states the process that would be carried out for admitting any new resident. Mencap have encouraged those local people who may wish to have a residential placement to complete an application form and go on the waiting list. Individual designed care plans list the assessed needs in different areas of each person’s life. The AQAA states: “As we have such a diverse group of residents it is important that we look at the person first and take on board their hopes/wishes/choices and try to find a way of meeting them. This may mean we work in different ways with each group of residents and within this group we look at different ways of working with individuals. Some of our residents are unable to verbally communicate and therefore it is important that the staff who work with these Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 9 individuals are clear about how these residents communicate their views and how they show if they are happy/unhappy/angry etc. The team leaders within these flats do advocate their interpretations of the views of their residents very well due to their in-depth knowledge of their residents and the close relationships we have with families of all our service users. This works in both ways in using their knowledge to help gain the views of the residents and also to advocate the resident’s view of feeling about something to their family.” The staff said that they have sufficient information and training to enable them to meet the needs of the people in the home. A number of staff, including the manager, have undertaken a distance learning course on Equality and Diversity. The home has been proactive in making sure that they can meet each person’s changing needs. They have advocated ion behalf of three people so that extra funding has been made available. One of these is a person who has developed dementia, and funding has been agreed to provide extra staff so that this person can enjoy increased individual activities. Stairways DS0000019550.V346792.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, 8 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who live in the home are actively involved in their own care planning and are consulted on every aspect of community life in the home. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) stated that the care plans have been updated and they are now “truly person centred”. The care plans address each person’s diverse needs, and each person has an annual Whole Life review. We looked at a sample care plan in each flat. They provide good details of the support that each person needs, and they are written clearly and from the person’s point of view. The focus of the care plan is to support each person to be as independent as possible and where possible to improving their skills for independent living. The staff who were spoken to said that the care plans provide them with good information on each person’s needs, so that they are able to provide a good quality of care in the way that each person wishes. Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 11 The ethos of the home is to encourage each person to live a fulfilling life, and to manage any risks positively so that people can lead the life they want. The AQAA states: “We pride ourselves on discussing and listening to what residents have to say and how they want to live their own lives. Our role is to ensure residents have the appropriate information to make well informed decisions. The service users who can articulate their views are always discussing both with their key workers and also the whole staff team that work with them what their views and decisions are about everyday issues that affect them. This could be in relation to their bedrooms and how they want this decorated or what they want on their walls ie posters, pictures etc. It may also be to discuss, choose or change the menus so that they are happy with what is served.” The people who live in Flat 4 are supported to take a full part in organising their own lives. One person told us that they go out independently, has their own bank account and that they looks after their own money. Everyone in the home has their own bank account, and for those who need more support there are good procedures in place. One person from each flat is a representative on the home’s health and safety committee, and they are encouraged to take some responsibilities for their role. Stairways DS0000019550.V346792.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, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home are encouraged to live full and active lifestyles. EVIDENCE: Everyone who lives in the home is from the local area. Their families are made welcome and are part of their lives, and the home is very much part of the local community. Each person has an individual programme from a wide variety of college courses and day care. One person has chosen to retire from formal day care, and extra funding was agreed so that they can follow their choice of activities in the home and the community. One person said that they had played golf earlier in the day, and another showed us a video of their college performance of Bugsy Malone. The Annual Quality Assurance Assessment (AQAA) states: “Service users discuss issues such as shopping trips, and on these decide what type of Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 13 clothing they wish to purchase, service users discuss the leisure activities they wish to take part in, for example one resident is a supporter of Luton Town FC and plans trips to home games with staff. She also chooses to purchase items from the club shop. We ensure that we have drivers to take residents to the clubs they wish to attend. One resident has a particular close friend at college. We liaise with the carer of this individual to arrange for them to visit for tea as requested by the resident, so that they are able to meet in an environment outside of college, especially during the long summer holidays. Listening to what service users have to say has resulted in changes such as changing college courses or assisting residents to look for work, enabling residents to spend less time at day centres and have a more person centred approach. Having ‘at home’ days for residents where they can access 1:1 staffing to carry out tasks or activities. Hiring a hydrotherapy pool for the use of residents who cannot or will not use a public pool.” Everyone takes part in the daily routines of their flat as far as they are able to. In flat 4, where people are more independent, they tidy and clean their own rooms and do their own laundry with the support of the staff. Each flat has its own kitchen, and meals are planned and cooked separately in each flat. There is a focus on healthy lifestyles. The staff support and encourage people to make healthy food choices, and to walk or use public transport more. Stairways DS0000019550.V346792.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. The home has an experienced and enthusiastic team of staff, who have the training and skills to provide a good quality of care for the people who live in the home, and to ensure that individual needs, choices and preferences are met at all times. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) stated that each person has an annual health check. There are good care plans on health and good health action plans. The staff have become more aware of healthy lifestyles and promote healthy diets and exercise. They are aware of changing needs for some people, and they have good relationships with GPs and specialists. The care plans that we saw provide good details of each person’s personal care and health care needs, and a good relationship was observed between the staff and the people in the home. Most of the people who live in flat 1 have complex physical needs. One person has a PEG feed. The staff said that they Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 15 feel confident in meeting each person’s needs, and they have good information and professional support to enable them to do so. The people who live in flat 2 have challenging behaviours. Their care plans contain clear details and procedures for behaviour management. The pharmacy inspector visited the home following the last inspection. He found that the home has very good written procedures for the safe handling of medicines. Record keeping is of a good standard. Weekly stock checks are carried out to ensure good stock control. However he said that key security must be improved to prevent unauthorised access to medicines; the use of a compliance aid for a resident who self medicates must be reviewed to ensure medication can be taken from correctly labelled containers; more suitable training of care staff on the safe handling of medicines must be considered. As a result of the pharmacist inspector’s advice the medication procedures have been revised. A local pharmacist, who has also provided accredited training for all the staff, now supplies the medication. The medication procedures have been reviewed, and there is a weekly audit of all medication to make sure that it is administered and recorded correctly. One person administers their own medication, and their medicines are provided in a monitored dosage dossette box. The only advice given on this occasion was to record the temperature of the storage cupboards later in the day, when the external temperature is warmer to ensure the continued effectiveness of medications as medication must be stored at the temperatures recommended by the manufacturer. Stairways DS0000019550.V346792.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. The people who live in the homes are encouraged and enabled to make their views and concerns known, and appropriate procedures are in place to ensure that they are protected from abuse and neglect. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) states: “We address any issues before a complaint is needed. We discuss issues with staff, residents or families at an early stage, so any issues can be addressed before they become official complaints. Residents know who to speak to if they are unhappy. We need to ensure staff know when somebody is making a complaint. Parents/residents do not always say or are able to say that they are complaining, but by saying something they are unhappy about or when saying “I am not complaining, but…” should be discussed as a complaint by staff.” One example of this came from a letter sent to the manager from a resident who is at home a lot during the week. They disliked the fire alarm being tested and became very upset due to the noise. The times and days when the alarms are tested are now alternated. The home has appropriate procedures for safeguarding vulnerable people, and all staff have training that includes understanding of these procedures. The staff spoken to were aware of the safeguarding procedures, and of their responsibilities for whistle blowing. Four incidents of physical intervention have been recorded in the last year. These relate to people in flat 2. There are very Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 17 clear procedures in place for behaviour management for each person, and all the staff have had Keeping Safe training. The interventions involve strategies for keeping the person safe, such as getting between people and distracting them. The record of the last incident gave clear details of the technique used, the duration of the intervention and the effectiveness of the strategy. Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the environment could be better suited to the needs of service users it is clean and well maintained. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) states: “We keep a safe, hospitable and very homely environment, that is decorated to the likes and tastes of the residents and incorporates the aids and adaptations needed. The atmosphere is friendly and sociable and we use the best of the building we have.” There are three separate self contained flats in the house for adults. A fourth flat provides respite care for children with learning disabilities. This was not inspected on this occasion, as children’s services are now regulated by Ofsted. Flats 2 and 4 have domestic style furnishings that suit the tastes and choices of the people who live there. Flat 1 has suitable equipment to meet the physical needs of the residents, including hoists and accessible bathrooms for Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 19 people in wheelchairs. In all the flats each person has their own bedroom that reflects their individuality. The bedrooms provide sufficient private space for each person, but the lounges and kitchens provide limited communal areas. Harpenden Mencap has plans for a new purpose built building, and they are currently negotiating for a suitable site. In the mean time the current premises meet the needs of the people who live there, and the management and the staff team ensure that the people who live in each flat have a comfortable home despite the limitations. The home appeared to be clean and well maintained, and appropriate policies and procedures are in place for the maintenance of hygiene and control of infection. Each flat has its own laundry facilities. In flats 2 and 4 there are domestic style washing machines in the kitchens, and people are supported to do their own laundry. Washing machines should not be sited in an area where food is prepared. However in these flats it was reported that there is no soiled laundry, and the risk of infection is therefore minimal. In flat 1 there is a separate laundry with appropriate laundry equipment. Stairways DS0000019550.V346792.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A stable staff team who have the experience and training to understand and meet their needs supports the people who live in the home. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) states that there is a dedicated staff team in each flat. The staff know the needs of the people in each flat well, and they advocate on their behalf where needed. They have good relationships with other professionals and good communication about the needs of the residents. (See Choice of Home and Personal and Healthcare Support.) The staffing rotas show that there are sufficient staff in each flat to meet the needs of the people who live there. Extra funding has been agreed so that three people can have extra one to one time. There is a stable staff team, and only two peop0le have left the home during the last year. The AQAA states: “Time for staff development and training has been a slight barrier, because of our person centred approach; we have residents at home every day and therefore releasing staff for training has proved difficult. We Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 21 have tried to overcome this by looking at buying in more training that can be delivered in house so we can limit the amount of times we need to release staff and also tailor the training to the needs of our residents. Time is also sometimes limited to review and update paperwork, this is due to staff wanting to spend time ‘hands on’ with residents rather than do paperwork. We have built time into the rota to release staff so they can update care plans etc, without this effecting time with residents, this has been achieved by the organisation putting additional hours into the rota.” All the staff who we spoke to said that Stairways is a good place to work. There is a lot of training available, and training has been provided for specific needs, such as challenging behaviour and dementia. The numbers of staff holding professional qualifications, NVQ s at levels two and three, considerably exceeds the requirement for 50 . The AQAA states that there are robust recruitment procedures, and that this year new CRB (Criminal Record Bureau) checks have been carried out on all the staff in the home. Stairways DS0000019550.V346792.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 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 managed for the benefit of the people who live there, and their views are actively sought and acted on. EVIDENCE: The ethos of the home is that it is the home of the residents, and the staff support them to live their lives as they wish to. Each flat has its own character that reflects the people who live there, and there is a family atmosphere in each flat. The manager has been in post for over four years. He has completed NVQ level 4 in both care and management. Both the manager and director have been awarded the Certificate in Personnel Practice (CIPD) this year, and the manager also has the NEBOSH (National Examination Board in Occupational Safety and Health) certificate for health and safety. The manager Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 23 and deputy manager oversee the whole home. In each flat there is a team of team leader, senior support worker and support workers. Harpenden Mencap is managed by a board of trustees, and the director provides effective support for the manger of the home and the service as a whole. The management have been proactive in ensuring that the service meets the changing needs of the people in the home. Additional funding has been negotiated for three people with specific needs, training programmes meet the needs of the staff, and each flat has equipment and furnishings that fit the needs of the people who live there. The staff who we spoke to feel very well supported by the management of the home. The Annual Quality Assurance Assessment (AQAA) states that the managers have regular contact with each flat and good knowledge of the needs of all residents. Managers attend all residents’ reviews. They lead by example and keep up to date with legislation and any other relevant changes. The AQAA provided evidence that there are good procedures for maintaining health and safety in the home. There are regular audits of health and safety checks in each flat. One resident form each flat is on the home’s health and safety committee. The incidents record provides good details of all incidents in the home, and the manager understands the need for notifying the appropriate authorities of any serious incidents. The director makes a formal monitoring visit every month that focuses on the views of the people who live in the home. The latest report states, ”I didn’t check any records on this occasion, as it was far better to be able to meet with people who were evidently happy living in the flat.” There are regular meetings with the people who live in the home, and the responses to their concerns and comments are sent to their families and are available in each flat. There is an annual survey of the people in the home and their families. The evaluation of the last questionnaire for families showed that they are very pleased with the quality of life that Stairways provides. Regular management meetings monitor the procedures in the home, and the views of the people in the home. Stairways DS0000019550.V346792.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 4 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 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 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 4 4 X 4 4 3 X X 3 X Stairways DS0000019550.V346792.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Stairways DS0000019550.V346792.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Stairways DS0000019550.V346792.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. 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