Inspection on 17/06/09 for Stephendale Road, 78-80

This inspection was carried out on 17th June 2009.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stephendale Road, 78-80 19/08/08

Stephendale Road, 78-80 09/07/07

Stephendale Road, 78-80 10/06/06

Stephendale Road, 78-80 06/09/05

Stephendale Road, 78-80 18/01/05

Stephendale Road, 78-80 27/09/04

Stephendale Road, 78-80 09/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Stephendale Road, 78-80 Stephendale Road 78-80 Stephendale Road Fulham London SW6 2PQ Lead Inspector Jacqueline Derbyshire Unannounced Inspection 17th June 2009 09:00 Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stephendale Road, 78-80 Address Stephendale Road 78-80 Stephendale Road Fulham London SW6 2PQ 020 7371 8908 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) rob.walker@yarrowhousing.org.uk Yarrow Housing Robert George Walker Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 Date of last inspection Brief Description of the Service: Stephendale Road is the home for six people with a learning disability. The care is provided by Yarrow Housing Limited, which is a voluntary organisation. Notting Hill Housing Trust owns the property. The home is located in a quiet residential street in Fulham and is close to transport links and local amenities. There are 5 people living at Stephendale Road presently, each person has a single bedroom. There are two bedrooms on the ground floor, two bedrooms on the first floor and another two bedrooms on another level up three steps. Washbasins are in each bedroom. There are WC, bathrooms and shower rooms situated close to bedrooms and communal areas. There is a passenger lift to the first floor. There is a garden to the rear of the home and a lounge and kitchen/dinning area. The weekly charge for Stephendale Road is £ 1,503.22. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Throughout this report the word we will be used as meaning the CQC Care Quality Commission. This unannounced inspection took place on Thursday 18th June 2009; we spent 4.00 hours visiting the home. We spent time talking to four of the five residents, the registered manager, deputy manager and a member of staff. We checked the care records of two residents and all medication and finance records were looked at. We had a full tour of the home and looked at three residents bedrooms. Stephendale Road has had some redecoration and we were told by the registered manager that the cyclical decoration plan is being slowly completed throughout the home. The home was in an adequate state of repair and residents told us they are happy with the décor in the home. We received five residents surveys and six staff surveys, comments from the surveys will be included throughout this report. 5 requirements set in June 2008 have all been fully met, 5 new requirements have been set from this inspection. We will make reference to the AQAA Annual Quality Assurance Assessment throughout this report. What the service does well: All of the resident’s are up to date with their person centred planning reviews, one residents meeting has been delayed the registered manager told us that is because of changes in the individual’s health and they are liaising with health professionals. The records looked at were relevant and up to date. We looked at two resident’s PCP reviews that were very informative showing photographs and pictures of what support each individual required. We were told by three residents that they are happy living at Stephendale road. They are happy with their rooms and we were told that the food is good. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: We looked at the statement of purpose that does require up dating and requires more information about the home to be included. We looked at the medication storage in the dining room; all records were seen to be correct as the procedure is that two staff members will always administer medication. The registered manger must make sure that all bottles of medicine have the date opened recorded on the label. We looked in the daily communication book that all staff will leave messages in for staff to read and sign to show they have read the information. There was an entry for the registered manager from the previous week that had not been read, the information was regarding fire exit signs in the home that had to be placed appropriately, and this information was left by the fire brigade that had visited to check fire extinguishers in the home. The organisation must make sure that sufficient staffing levels are in place to provide all residents with an appropriate activity programme as written in their person centred planning. All surveys returned to the CQC had comments regarding more staff required for activities. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 7 The registered manger must make sure that all staff follows the correct health and safety procedure for the safe storage of frozen food, as we looked in the two freezers and packets were open, not resealed, with no date opened and use by date. The organisation must make sure that the cyclical programme of redecoration is completed so that the residents have a comfortable home to live in as written in the homes statement of purpose. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Stephendale Road, 78-80 DS0000019144.V375894.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 Stephendale Road, 78-80 DS0000019144.V375894.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a statement of purpose that is specific to the individual home and the resident group they care for. The home does need to up date the document to inform resident’s and stakeholders of the homes aims and objectives. EVIDENCE: Comments from residents and staff. I really like living here ‘Staff make sure that they treat all residents equally’. ‘I like it here and my room is really lovely’. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 10 We looked at the statement of purpose and service user guide, the statement of purpose requires to be updated and include all information on the aims and objectives and philosophy of Stephendale Road. We looked at records in two resident’s files that show that their needs are assessed and reviewed regularly. Person centred plans were looked at with risk assessment records that worked in conjunction with the PCP records. We looked at two resident’s agreements; the records were up to date and are reviewed annually. Both records were signed and dated by the residents. All original contracts are kept at the Yarrow head office. Stephendale Road, 78-80 DS0000019144.V375894.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service will know and record the preferred communication style of the individual, and will use proven methods that enable the person to lead a full life that promotes independence and choice. Staff understand the importance of all resident’s being supported to take control of their own lives. EVIDENCE: Comments from residents and staff. I am doing well, staff fulfils my needs. ‘We listen to and support all residents very well’. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 12 We looked at two resident’s files, both included person centred plans with lots of reviewed records. The PCP plans are informative and relevant to each individuals needs. The PCP plans do reflect the aims and aspirations of the residents; one showed that the individual would like to go on holiday. Another resident had that they would like to go visit their girlfriend; records show they do this on a weekly basis. The PCP plans do reflect the individual’s health and social care needs and how the staff are meeting each persons needs. The PCP’s were in pictorial formats and also on DVD, showing how the individuals are involved in their person centred plans. Staff was seen to promote the residents independence assisting them when requested and not telling the residents what to do. We looked at the risk assessments for two resident’s, all of the risk areas identified in the care plan had an action plan in place to inform staff of the risk and how to eliminate or minimize the risk. The risk assessments did work in conjunction with the care plans. Stephendale Road, 78-80 DS0000019144.V375894.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. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: Standards 12,13,15,16 and 17. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are involved in meaningful daytime activities of their own choice and according to their relevant interests, diverse needs and capabilities. EVIDENCE: Comments from residents and staff. I do a lot of activities. Staff support me to go out every day I am happy. ‘I would like more trips out’ ‘We should provide more activities’. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 14 ‘I like the food, I help to cook sometimes’. ‘The home provides good food’. We looked at the person centred plans of two resident’s; the records contained a lot of information about each resident’s likes, dislikes, hobbies and leisure interests. We also looked at the daily records for all five resident’s that had information about what activities they had done daily that included attending a local cafe, going to the local community centre called the Gate, attending dancing classes, art classes, discos, eating out, and for all residents attending the local church on a Sunday. We discussed comment made in surveys returned to the CQC stating that resident’s require more staff input to provide an appropriate activity programme, we were told by the registered manager that there are difficulties in escorting residents out as one resident now requires one-one staff input at all times. We looked at the rota for staffing in June 2009 that shows there is a need for more staff to provide appropriate activities for all residents. We looked at the contact information for two resident’s, two resident’s contacts their friends on the telephone on a regular basis and also visit them in their homes. Their friends also visit Stephendale Road. Another resident goes to spend time with their boyfriend. In discussion with the registered manager we were told that resident’s are always encouraged to continue relationships with their family and friends. We were told by the registered manager that the big shopping is done weekly and staff and resident’s will shop more regularly for perishable items. We saw a lot of fresh food at the home. We were told by resident’s that they enjoy the food, one resident was seen to help them self to breakfast and hot drinks when they wanted them. One resident has a special diet and staff will liaise closely with them to make sure they are provided with variety. We saw the weekly menu that is pictorial format in the kitchen; resident’s choose the menus at their weekly house meeting. The AQAA form completed does go into detail about the different diverse needs of the residents and how staff do try to provide a varied menu. Stephendale Road, 78-80 DS0000019144.V375894.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, and 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal and healthcare support using person centred approach with support provided based upon the rights and dignity, equality, fairness, autonomy and respect. Personal healthcare needs including specialist health; nursing and dietary requirements are clearly recorded in each person centred plan. EVIDENCE: We looked at two resident’s files, both included information on what level of support they require. On the day of this site visit staff were seen to be encouraging the residents, personal and healthcare support is provided in a person centred way. All five residents require different levels of support from full support to prompting an individual; the information was clear in each PCP plan looked at. We saw information on how the home had liaised with other professionals including speech and language therapists, psychologists, psychiatrists and social workers. One resident that has been diagnosed with Alzheimer’s has been granted continuing care from the NHS. The information in the resident’s support plan is very informative and up to date. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 16 All of the resident’s living at Stephendale Road are registered with a local GP. We looked at the medication records for all five resident’s that were well recorded; there is two staff that administers medication at all times. We looked at the storage of medication that is in the kitchen/dining room, the registered manager must make sure that all bottles of medicine opened have the date of opening recorded on the label, to make sure that residents are not given out of date medicine. We looked at staff training records and all staff except one individual that has recently returned to work after being absent has attended medication training. We were sent the date of medication training that the member of staff will attend. The registered manager told us that the medication training person from Yarrow has liaised and stated they will go to Stephendale Road and provide a refresher session for all staff. Stephendale Road, 78-80 DS0000019144.V375894.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. It is available in different formats to help anyone staying at or involved with the service to complain or make suggestions for improvement. EVIDENCE: Comments from residents and staff. I will speak to staff if I am not happy. ‘I will speak to the manager if I have a complaint’. We looked at the complaints file that had no complaints logged, however the information was in place to show how the staff would deal with any complaint raised. We were told by the registered manager that all staff is aware of what to do if a complaint or issue was raised. The complaints procedure was on the resident’s notice board in the dining room. The complaints procedure is available in different formats including pictorial. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 18 We spent time discussing the safeguarding policy and procedure with the registered manager and deputy manager. The registered manager discussed the incidents that had occurred in 2008 and how it was a difficult time for all staff and residents. The registered manager has put in place the organisations safeguarding policy and procedure and the local authority procedure for staff to follow if an incident occurs. We looked at the training records of all staff and all staff except the member of staff returning back to work has attended training, we were told that the member of staff will be attending refresher training. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 28 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of home is reflected in the statement of purpose, it is comfortable and homely. Resident’s are encouraged to personalize their own bedrooms. All of the homes fixtures and fittings meet the needs of individuals and can be changed if their needs change. The home is accessible for people with a physical disability as there is a lift to access all floors. EVIDENCE: Comments from residents and staff. I am happy with my bedroom. I like living here . Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 20 ‘I love my bedroom I have lots of nice things’. ‘The home is safe and comfortable for all residents’. We had a full tour of the home and all areas were seen. Stephendale Road cyclical redecoration programme has started with four of the five residents bedrooms having been decorated. We were told by the registered manager that the other residents bedroom and the vacant bedroom is planned to be completed soon. New lino flooring has been put in some communal areas we were told by the registered manager that the top landing will be done imminently. We were told by two of the resident’s that they are happy with the decor. We spent time with two resident’s in their bedrooms that were seen to be comfortable and had a lot of personal items in place. One resident has chosen to purchase some furniture them self that is very fancy; the resident told us they like buying nice things. We looked at all communal areas of the home, the lounge was adequate, and the bathrooms were adequate. The kitchen was fit for purpose. The home was clean, tidy warm and bright on the day of this site visit. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34, 35 and 36. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is not enough staff available to meet the needs of all residents. Staff rotas do not take into account the activity needs of the people using the service. EVIDENCE: Comments from residents and staff. The staff are nice they help me. I am very happy with the staff. ‘We need more staff to provide more activities to residents’. We looked at the staff rota for June 2009, there was adequate staffing on each shift to meet the care needs of the five residents, however there is not sufficient staffing to provide a full activity programme for all resident’s especially trips into the local community. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 22 We spent time discussing staffing with the registered manager and were told that there are two vacancies in Stephendale Road that are sured up by regular bank staff. We were told by resident’s that they liked all of the staff. We were sent the CRB information on all staff and bank staff currently working at stephendale Road, all disclosures were up to date. We looked at the training records of all staff that show that all staff is up to date with training, there is a member of staff who is currently completing refresher training as they have recently returned to work after being absent. We spent time at the organisations head office in December 2008 looking at staff recruitment records, all of the relevant checks were seen to be in place. All staff recruitment records are kept by the human resources team in safe storage at the head office. The registered manager and deputy manager are registered to complete an NVQ level 4; we spent time discussing the continuous training of all staff with the registered manager who told us all staff is up to date with training. Records were looked at showing that staff is attending training and keeping up to date in the organisations training programme. There are currently five members of staff with an NVQ and two who are registered to complete the qualification. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has a clear understanding of the key principles and focus of the service, based on the organisational values and priorities. EVIDENCE: Comments from residents and staff. Full support is always given from the manager. I am happy living here. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 24 The registered manager has worked in social care for many years and is very experienced; the registered manager is registered to complete an NVQ level 4. We spent time throughout this site visit discussing all areas of running the home, the registered manager is very positive about the care provided by the staff team and discussed the person centred approach that all staff follow making sure all three residents independence is promoted. We spent time discussing the organisations quality assurance procedure with the registered manager. We looked at questionnaires that hade been completed by residents, advocates and other professionals that work with the residents. We saw a lot of positive comments about the care provided at Stephendale Road. The organisation produces an annual survey of all of the homes including Stephendale Road. We were given in formation in AQAA returned that shows that all health and safety checks are completed on a regular basis. We looked at records for checks for the fire alarm system, tests and evacuation records, safe food storage, water temperatures and gas and electric maintenance, all were seen to be well recorded and up to date. All staff training records were looked at and all staff except a member of staff returning to work after a long absence has completed first aid training, we were told by the registered manager that the member of staff will be attending all relevant training imminently. We looked at the storage of food in the two freezers, the registered manager must make sure that any packets of food opened are resealed with the date opened and use by date recorded on a label. We looked in the daily communication book that all staff will leave messages in for staff to read and sign to show they have read the information. There was an entry for the registered manager from the previous week that had not been read, the information was regarding fire exit signs in the home that had to be placed appropriately, and this information was left by the fire brigade that had visited to check fire extinguishers in the home. We discussed this entry with the registered manager who told us that he will deal with the information and implement the recommendations left by fire brigade officer. Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 x 4 x 5 3 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 x 27 x 28 2 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 x 36 3 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 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 2 x Version 5.2 Page 26 Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc 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 YA1 Regulation 4 Schedule 1 13 Timescale for action The registered manager up dates 17/09/09 the statement of purpose to include all relevant details for prospective residents and the people living at the home. The registered manager to make 30/06/09 sure that all medicine bottles have the date opened on the label to make sure residents are protected. The registered manager and 17/08/09 organisation must make sure that there is sufficient staff on duty to meet the activity programme for all residents living at the home. The registered manager must 22/06/09 make sure that the recommendations from the fire brigade are implemented to protect the residence and staff. The registered manager must 22/06/09 make sure that all staff are aware of the procedure to safely store frozen food that has been opened to protect residents. Requirement 2 YA20 3 YA33 18 4 YA42 23 5 YA42 13 Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 27 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 Stephendale Road, 78-80 DS0000019144.V375894.R01.S.doc Version 5.2 Page 28 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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