Inspection on 11/07/07 for Stepping Stones

This inspection was carried out on 11th 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

Stepping Stones 04/07/06

Stepping Stones 20/10/05

Stepping Stones 14/04/05

Stepping Stones 18/11/04

Stepping Stones 10/06/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Cornerstones

Bethesda

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

CARE HOME ADULTS 18-65 Stepping Stones 1-6 Boxhill Close Chard Barton Honicknowle Plymouth Devon PL5 3QB Lead Inspector Kim Fowler Key Unannounced Inspection 11th July 2007 11:55 Stepping Stones DS0000003560.V335458.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 Stepping Stones DS0000003560.V335458.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. Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stepping Stones Address 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) 1-6 Boxhill Close Chard Barton Honicknowle Plymouth Devon PL5 3QB 01752 788273 01752 768613 tamarstepping@waitrose.com Tamar Housing Society Mrs Susan Davidson Care Home 15 Category(ies) of Physical disability (15) registration, with number of places Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age 18-65yrs Date of last inspection 4th July 2006 Brief Description of the Service: Tamar Housing Society, which is a housing association registered with the Housing Corporation own Stepping Stones. The home is a care home providing care for fifteen people, aged 18 - 65, with physical disabilities. The home is for long stay placements but do try to aim to work with service users to develop independent living skills to enable them to move out into their own accommodation. The length of stay depends on the individuals needs as identified with the Care Manager and through care plans. The home is located at the end of a cul- de- sac on a housing estate in the residential area of Honicknowle, close to shops, pubs, the post office and other amenities. The home is purpose built and was opened in 1994. It is comprised of two selfcontained bungalows, each providing six bedrooms, and three one-person flats. All the homes bedrooms are single and bedrooms in the bungalows do not have en suite facilities. Each bungalow and flat has its own facilities, amenities and services with the design and layout enabling ease of access for people whose main source of mobility is wheelchairs. The home has plenty of communal space and consists of a kitchen and combined dining and lounge areas in each bungalow. The home has spacious and attractive grounds, with raised flowerbeds, which are accessible by service users. Fees start at £600 a week. Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 1 day and started at 11.55am and finished at 5.50pm. The registered manager Sue Davidson was available throughout the inspection. The inspector made a tour of the building and spoke to most of the people living at the home. Documentation relating to the care planning process and the management of the home were examined. Six surveys for people living at the home, two relatives and one professional survey were returned to the Commission. Any comments are discussed in the relevant section of the report. What the service does well: What has improved since the last inspection? What they could do better: Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 6 No Requirements or Recommendations have been made in this report. 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. Stepping Stones DS0000003560.V335458.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 Stepping Stones DS0000003560.V335458.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): 1/2/3/4.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective new service users can be assured that the home will complete a detailed pre-admission assessment to assist staff to meet their individual needs. EVIDENCE: One person recently admitted to the home stated that they had received information about the home prior to admission. This person’s file held evidence of copies of letters sent to them stating the Statement of Purpose and Service Users Guide had been sent before admission. Six other people’s files were examined and the file of the last two people admitted to the home held a completed pre-admission assessment. This assessment was supported by the placing authorities care plan and assessment. One person recently admitted was spoken with and confirmed they had provided information to the home, with assistance from their family, in the completion of the pre-admission assessment ensuring that the staff had full information to assist them in carrying out their daily duties. Further files examined provided evidence that care plans were held and each file contained comprehensive individual care plans. These documents provided Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 9 all the relevant information required to meet the assessed need of the people living at the home. A comprehensive list of care needs held on each file allows the staff to access information to meet the complex needs of some the people living at the home. These details included information on how to meet people’s personal care needs and to deal with any aggressive behaviour. Completed assessments are important to assure that not only can their health care needs be met but also their emotional, social, cultural or religious needs. The staff spoken with agreed that the information provided on each file assist them to meet the needs of each person and in such a way that it promotes independence. One relatives survey returned to the Commission stated, “Our daughter’s needs do change on a regular basis and we find that the care home responds well to this after speaking to our daughter”. One person confirmed they had visited the home several times prior to admission and the dates and times of these visits were recorded as evidence. Stepping Stones DS0000003560.V335458.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): 6/7/9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are encouraged and supported to make daily decisions about their own lives to maintain their independence. EVIDENCE: All six files examined held individual care plans in place and the details held on these files are needed by staff to provideindividual needs. These care plans show a breakdown of the services and facilities provided by the home as well as current needs, specialist input and guidelines for staff to manage incidents of verbal aggression. These plans provide staff with the information on how to care for each person and ensure continuity in care and have been completed to enable staff to carry out their duties and ensure all aspects of health, personal and social needs were met. Many of the people living at the home are able to make decisions about the own lives and include when to go out and managing their own finances. The manager stated that each person is given options about were to go on holiday and then discuss the options available and choose their destination. Many Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 11 people spoken with confirmed that they choose were they went on holiday and one person said, “ One of my friends went to Portugal so I chose to go there this year”. The manager stated that all people living at the home have their own bank account and all go to collect and draw their money. Some keep their money and some choose to use the locked facilities available in individual bedrooms. All cash tins hold a record book and records all expenditure and receipts are held as evidence. If staff access these tins on peoples behalf two staff are required to sign the withdrawal to ensure the protection of peoples money. Some money is kept by the home for some people who are unable to manage their own finances and the homes system was examined and checked. The cash held was checked and found to be correct. Evidence was provided of a clear audit trail of expenditure, income and people were required to sign for money as they withdraw it. The manager stated that everyone receives their own Disabled Living Allowance, Personal Allowance and benefits paid direct into peoples own bank account. Several people living at the home confirmed that they do hold their own money and spend this how they wish. One person said, “I have my own cash card and draw money when I wish”. This promotes peoples independence. All care plans held risk assessments to cover all aspects of risk. These risk assessments included independent living skills and manual handling risk assessments with assistance on using the hoist if required. This information is important to minimize risk. Stepping Stones DS0000003560.V335458.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): 12/13/14/15/16/17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in Stepping Stones can be confident that the home will promote and provide support for them to access the local community and leisure activities while promoting independence. EVIDENCE: The manager stated that no one currently holds paid employment however on person is actively looking for work. Two people are undertaking volunteer work and several other people attend the local college. Courses recently completed, before the end of the summer term, included Adult Literacy and Numeracy, art, music and computer skills. Evidence was provided by one person’s certificate of achievement displayed in their bedroom. This person also said they had attended the college and were applying for the new term. The manager stated that the home had obtained Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 13 the 07/08 Prospectus and had plans to discuss this at the next homes meetings. Due to the lack of day services available the home has set up activities inhouse for people to attend. Observed during the inspection was the home’s staff taking a group activity. The staff stated that each day a different activity is undertaken and includes writing and women or men groups. One person said, “Sometimes we do cooking” and other people said they enjoyed the groups. Several people were attending a local disco the evening of the inspection. And one person said, “ I am going to a disco at the local football club” and another person was observed talking to the manager and staff about the time and who was going to the disco planned for that evening. Many people informed the inspector of different activities undertaken. This included trips to the Theatre, cinema and the local town shopping. Two people were away on holiday on the day of the inspection, two people were going away the next day and two people were returning from their holiday on the day the inspection was carried out. The comments received from people included, “I had a great time on my holiday”, and, “I’m going to the airport tomorrow and have my case packed ready”. Evidence was recorded in the files examined of input from relatives and friends. The staff confirmed that several people have regular visits from family members and some people visit the families at home. One person said, “My mum comes to see me” and another person said, “I go out every week to meet my friends at the pub”. Every person spoken with who was able to confirm that the staff knock on their door to gain entry. All care plans seen showed they are based on the promotion of independent living skills. The home’s daily activity planner includes everyday activities to include meal planning and cooking to maintain their living skills. Staff were observed knocking on peoples door to gain access. Information held on files is used to promote the respect, privacy and dignity of each service user in the home and the home and the grounds are assessable for wheelchair access and was purpose build to include wide doorways and ramps, further promoting independence and freedom of movement. One relative wrote when asked what the care home does well, ”Encourages the clients to lead a more independent life”. The manager stated that the menus are discussed with everyone living at the home and evidence was provided that each day’s menu was written on a large Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 14 notice board for people to see and accompanied by drawing. The staff stated that the kitchen is accessible at all times and observation during the inspection showed that people accessed the kitchen with support from staff and helped in the preparation of meals and drinks. The staff spoken with confirmed that the home has a good food budget with plenty of provision and choice available. The home has three self-contained flat and the people who live in the flat said they plan their own menus and go shopping. They then have staff support, if needed, to assist them with cooking and preparing the meals. Everyone spoken with about the food and who were able made positive comments and person stated that they go to the local shops to assist with the shopping. One person said, “ I like the food” and another stated, “I have a choice and help staff with the cooking”. Observed during a meal served provided evidence that everyone has staff support and specialist equipment if required and this promote independence at meal times. Stepping Stones DS0000003560.V335458.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18/19/20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living at the home stated that the staff promote their independence and provide very good personal support promoting privacy and dignity at all times. EVIDENCE: All personal support is recorded into individual care plans and these are easily accessible for staff and all rooms are single. These care plans are held in individual bedrooms for access by staff and the people who they relate too. This ensures consistency in the care provided. These care plans are based on assessed needs and evidence was recorded that these are regularly reviewed and then signed. Guidance on personal care is clearly recorded into individual files and supported by documents including, “how to clean teeth”. This ensures that staff are aware of peoples needs and will promote consistency in care. A discussion with most of the people in the home confirmed that they agreed that the staff supports them with their personal needs and in a way with is suitable to them. One person said, “They always shut the bathroom and bedroom door when helping me”. Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 16 Files examined provided evidence that specialist support is provided and included attendance of Occupation Therapist services. Other files contained letters for hospital out patient appointments and confirming future dates arranged. This ensures that service users health needs are met and that specialist input is saught. One person stated, “ I see a physiotherapist once a week” and another said, “I go to a local gym for physiotherapist treatment”. One person had injured their foot on the day of the inspection and records showed that this person attended the local surgery and had their injuries dressed by the surgeries nurse. Further case tracking showed that this information was recorded into the person individual file and daily records. The manager had also completed a new risk assessment form to make staff aware and to prevent further injuries. The medication system was checked during this inspection and found to be well recorded and documented. All staff designated to administer medication have received medication training. The local PCT (Primary Care Trust) or pharmacist has provided medication training on the use of the medication system in place as well as the administration of suppositories. The manager has also completed her “Management of Medicines” course with the Alliance Pharmacist and will promote the home policies and procedures. All files examined held a form signed by the person concerned to say that they give permission “for the home staff to administer medication”. One staff member confirmed that only senior staff administer medication and that they had also received regular updated medication training. Stepping Stones DS0000003560.V335458.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22/23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Stepping Stones can be confident that any complaints or concerns raised will be listened to, acted upon and well managed by the home, which protects the welfare of all. EVIDENCE: The home has a complaints procedure in place and has a designated complaints file. Several complaints were recorded and documented. These showed the outcome, timescale and actions taken. The manager confirmed that all complaints had been satisfactorily dealt with. Some people spoken with said they were either aware that the home had a complaints procedure or would talk to the manager or staff if they had any concerns. One newly admitted person said “I know there is a complaints procedure but have not needed it”. One person said, “I was upset about something today and went to see the manager and I’m alright now”. One staff stated during interviews that they felt that people’s views would be listened to and acted upon. The manager confirmed input from the local advocacy service would be saught if required to assist people. One survey received from some one living at the home under the do you know how to make a complaint wrote, “Speak to the manager”. The Commission has not received any complaints. Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 18 One Adult Protection issue had been raised since the last inspection. Discussion with the manager and recorded evidence shows that this issue was dealt with and staff members spoken with. The manager has also purchased a training video on adult protection to assist with updating staff training. Many staff members confirmed that they had completed the local Adult Protection training. From discussion with the staff it was clear that they were aware of the procedure for the protection of vulnerable adults. Stepping Stones DS0000003560.V335458.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24/30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Stepping Stones continues to maintain a clean and suitable environment for it’s stated purpose and people living at the home can be assured that they will live in a comfortable home that is regularly maintained. EVIDENCE: Stepping Stones is a purpose built home with two bungalows accommodating six people in each and three individual flats. The premises are accessible to all the people living at the home with level access throughout, automatically opening front doors and two-way bedroom doors. Areas inspected were found to be comfortable, well furnished and clean. All areas are assessible for wheelchair access and were bright and cheerful. Some minor repairs were noted mainly from wheelchair damage on the paintwork. The manager stated that the paintwork is regularly painted. Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 20 The quality of the home was good and the home has a rolling maintenance programme ensuring that all areas of the home are regularly maintained. Many people living at the home showed the inspector their bedrooms and each bedroom was personalised with many personal possessions. One bedroom had recently been decorated and the manager stated that the person occupying the room had choosen the new colours and the family had decorated this room while this person was on holiday. The home has the aids and adaptations, such as hand/grab rails, bath/mobile hoists and electric/manual wheelchairs, to meet the needs of the service users. The home has a call alarm system in place as well as being adapted to accommodate wheelchair users with such items as lowered light switches, accessible power points, lowered work surfaces, sinks and cooker hobs that moved up and down, and recharging facilities for wheelchairs. All the bathroom and toilet doors are fitted with a lock that can be overridden from the outside maintaining both the privacy and safety for all. A good quality of living environment gives people living at the home a better quality of life. One bottle of chemicals was found in an unlocked cupboard. However the manager had already recorded into the staff communication the importance of locking unused items away for the safety of people who live at the home. The laundry facilities are sited separately and the home was clean, hygienic and free from offensive odours and the laundry facilities were suitable for its stated purpose also the washing machine has a sluice facility. The process for the removal of clinical waste was discussed and was satisfactory dealt with. One staff member confirmed they had completed infection control training and observation showed that the home provided disposable aprons and gloves for their protection. Stepping Stones DS0000003560.V335458.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32/34/35/36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at the home are supported by well-motivated and caring staff in sufficient numbers to meet the needs of those currently living at the home. Staff training, supervision and appraisals are carried out regularly to all staff to ensure that all assessed needs of the people living at the home are met. EVIDENCE: 5 staff members were spoken with and 6 staff files examined during this inspection. The staff spoken with during the inspection confirmed the training they had attended and course’s planned. Staff also confirmed that Tamar Housing and the Registered Manager promote the staff’s training and development. The staff and manager confirmed that all staff either holds an NVQ qualification or presently working towards it. Several staff spoken with already holds an NVQ level 2 and are being supported to continue and gain and NVQ level 3. Staff files examined all held training certificates including course completed on First Aid, Manual Handling and Food Hygiene. Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 22 Those staff files examined contained the required pre-employment checks, including Criminal Record Bureau Disclosures (CRB), ensuring as far as possible unsuitable staff are not employed. The files examined showed that all newly appointed staff members had received Induction training. One newly appointed member of staff spoken with confirmed a probation period, CRB clearance and shadowing of experience staff when first employed. All staff confirmed regular supervision and staff files examined provided evidence that supervision records were held. One staff member confirmed that the home holds regular staff meetings and supervision sessions. All staff stated that they were able to express their view at these meetings. Regular consultation with staff ensures staff can contribute to the running of the home and are aware of the home’s aims and objectives, philosophies of care and promotes consistency and improvement. A NVQ assessor visiting the home during the inspection to assist staff with the completion of their NVQ’s was spoken with. This visitor confirmed that Tamar Housing and in particular the manager was supportive and actively involved in the staffs progression. One staff member said of the staff team, “It’s an excellent staff team”. People who live at the home made the following comments about the staff, “They are nice” and “The are pretty good”. And one said, “They are really really nice”. One relative survey wrote, “We cannot speak highly enough of the staff and in particular the manger and the level of care she produces”. Stepping Stones DS0000003560.V335458.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37/39/42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of this home is very good and ensures that records are effectively maintained. And the staff team are well trained to meet the needs of people living at the home. EVIDENCE: The Registered Manager Sue Davidson is a qualified nurse and has the Registered Managers award and continues with her own personal development by attending course to assist staff training. This has included recent courses on Fire Marshall training, Risk Assessments and undertaking the Infection Control Diploma. The manager also is a member of the Joint Devon Care Training group. Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 24 The manager also sits on the local Infection Control group to promote hygiene issues within the home. One staff member stated that the manager was “approachable and assisted with any personal problems”. Another staff said, “The manger has been more approachable recently and things had improved”. The manager provided evidence that she has developed a new quality assurance questionnaire. The manager stated that this would be distributed in September after all the planned holidays. Previous inspection recorded that quality assurance surveys had been sent out to people living at the home. Several people confirmed attendance at house meeting and issues including menus planning and holidays were discussed. Sampling of servicing records indicated that equipment is serviced regularly and maintained in good working order, including the fire alarm system. Certificates were available on all Health and Safety equipment i.e. hoist ensuring all have been checked. Gas and electrical appliances were being routinely serviced and checked. The fire protection system was well maintained. Maintenance checks are being carried out. Staff are receiving appropriate fire protection training to ensure they have the skills to deal with emergencies. All staff have completed manadatory training in Fire safety, First Aid and food hygenie. The staff spoken with confirmed the completion of these courses and certificates were held on individual files. Good health and safety practices reduce any unreasonable risk, affecting people living at the home, to an acceptable level. Stepping Stones DS0000003560.V335458.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 3 2 4 3 3 4 4 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 3 X X 3 X Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 26 N/A 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. 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 Stepping Stones DS0000003560.V335458.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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