Inspection on 04/07/06 for Stepping Stones

This inspection was carried out on 4th July 2006.

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 11/07/07

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 Unannounced Inspection 4th July 2006 10:00 Stepping Stones DS0000003560.V292656.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.V292656.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.V292656.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 tamerstepping@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.V292656.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age 18-65yrs Date of last inspection 20th October 2005 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. Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and the site visit was undertaken on 4th July 2006. The Registered Manager, Mrs Sue Davidson, was present throughout the site visit. The inspector made a full tour of the premises and 10 service users were spoken with. Staff on duty were observed and 5 were spoken to in the course of their daily duties. Service users and staff records were inspected. Following the visit to Stepping Stones the Commission has received 1 relative’s feedback card, 1 Health and Social Care feedback card, 4 staff questionnaires and 2 service users feedback surveys. What the service does well: What has improved since the last inspection? One service user informed the inspector that they had their bedroom decorated since the last inspection and they had assisted in choosing the colour and other items of soft furnishings that were bought. Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 6 The home has an ongoing maintenance plan and redecoration work is of a high standard indicating that the owners are committed to ensure the service users are in a very comfortable home. The manager is developing a Day Care activity programme in response to the closure of local day services; this will encourage service users to pursue their own interests and hobbies and promote their independence. 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. Stepping Stones DS0000003560.V292656.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.V292656.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2/4 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users can be assured that the home undertake a detailed preadmission assessment which will be used to assist staff to meet individual needs. EVIDENCE: Service users files examined provided evidence that a new service user had a pre-admission assessment completed by the placing authority. The registered manager confirmed that she had visited this service user before admission. The home also completed a Tamar Housing pre-admission assessment ensuring that the care needs of this service user can be met by the home. Further files examined provided evidence that pre-admission information was transferred to the service users individual care plan. This information is important so service users can be assured that not only can their health care needs be met, but also their physical needs. Recorded in one service user’s file was information to show that they had been referred to an Occupational Therapist, Physiotherapist and Wheelchair service for re-assessment of their physical abilities. This was done so as to provide appropriate equipment so their needs could be met. Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 9 The inspector spoke to this service user who confirmed that they had attended the wheelchair service and been assessed for equipment. This service user also confirmed that they had assisted in the completion of the pre-admission assessment ensuring that the staff had full information to assist them in carrying out their daily duties. The new service user and the manager both confirmed that the service user had visited the home for several trial visits before moving in. This provided an opportunity for both parities to assess the suitability of the environment. Stepping Stones DS0000003560.V292656.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6/7/9 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users are encouraged and supported to make decisions about their own lives in order to maintain their independence. EVIDENCE: Four individual service users files were examined. They provided evidence that all service users have comprehensive care plans in place. These care plans ensure that staff are aware of service users needs and will promote consistency in care. The information recorded in the care plans included input from the service user. This involved the service user signing and agreeing their annual reviews with their facilitators assistance. These detailed care needs provide the action required by staff to meet the needs of each individual service user. These care plans are currently being updated and reviewed. All care plans included risk assessments that covered all aspects of risk. These risk assessments included independent living skills and whether service users Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 11 access the community with assistance or independently. This information is important to minimize risk. The home has a facilitator system in place and discussion with the service users in the home confirmed that they have regular individual discussions and time with their chosen facilitator. One service user confirmed that they had had a change of facilitator and this was at their request. During the inspection some service users were observed having discussions with the manager about making decisions and choices in their own lives. These discussions were about daytime activities and their involvement. Also discussed were personal finances and plan expenditure. This evidence showed the manager encouraging the service users independence and decision making. A one-service user was planning how best to spend their money. One service user informed the inspector that the staff assist them to make decisions about everyday issues and that they hope to live independently in the near future. A service user survey received stated, “ I like Stepping Stones and I like being Independent”. All service users have their own bank account and cash card. They withdraw their own money and hold cash in a tin kept in a locked cupboard in their bedroom. This tin has an expenditure book to record when and how the money has been spent. To protect all service users the manager or senior staff regularly check the balance and expenditure in the tin. If larger sums of money are required then this is held securely in the homes safe. During the inspection one service user was in discussion with the manager planning a trip to the bank to withdraw extra funds. The home uses this system to protect the service users and promote independence and minimise risks. The manager was in discussion with 2 service users about attending a local Tai-Chi class. The service users and manager discussed the benefits and any risks involved due to the physical disabilities of the service users. Each file examined during this inspection contained risk assessments with information for everyday activities. Stepping Stones DS0000003560.V292656.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,17 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The service users in Stepping Stones can be confident that the home will promote and provide support for them to access the local community and leisure activities. EVIDENCE: The inspector talked to some service users about day time activities. Observed during the inspection were service users planning day care activities to take part in valued and fulfilling activities. One-service user was going to look at a computer course and the possibility of taking up opportunities for further education. One service user had gone to the bank during the inspection and discussed with the inspector the process they use to collect their money and how the home promotes their independence. Service users files showed that each service user has a daily planner to record their personal development. Due to the recent changes and reduction in day care placement in the local area these Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 13 are currently being updated but still promote the independent living skills of each service user. The homes manager discussed with the inspector the homes plans to organise in-house activities based on service users needs. One session to start with will be about Money Management that will assist service users to make decisions and choice about money matters. Several service users were accessing the local community on the day of the inspection including the local hairdressers and shops. On discussion with the service users individually and in groups all confirmed that they go out into the local community regularly, some with staff support and some on their own. The home also has a daily activities/ going out book for staff to record when service users had been out to ensure that all service users go out regularly. The manager informed the inspector that they had a good relationship with the local community. All service users spoken with during this inspection said that they either have family or friends that visit the home or they go out to visit them regularly. One service user said they go on holiday with their family. This ensures service users maintain family links and have friendships inside and outside of the home. Each service user has a single room and are able to see visitors in private. Some service users attend local colleges and courses open to the general public promoting community links and social inclusion. All care plans seen showed they are based on the promotion of independent living skills. The home’s service users daily activity planner includes everyday activities which include meal planning and cooking. This promotes their independent living skills. The home was purpose build to accommodate people who have a physical disability. The grounds are assessable for wheelchair access and there are wide doorways and ramps. All the service users said that meals are of a good standard, and that the menus were satisfactory. Some service users living in the flats design their own menus and plan the shopping based on these menus. They then have staff support, if needed, to assist them with cooking and preparing the meals. Stepping Stones DS0000003560.V292656.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18/19/20 Quality in this outcome area is good because service users can be confident that the staff will promote their independence by providing good personal support. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Files examined provided evidence that all service users personal support needs are clearly recorded in individual care plans. These care plans are held in service users individual bedrooms for access by staff and service users to ensure consistency in the care provided. These care plans are based on assessed needs have recently been reviewed. The service user then signs these plans when they have agreed them. This is carried out with the assistance from their facilitatorr. Any changes and updates based on risk assessments and manual handling needs were also updated. Service users confirmed that the staff supported them with their personal needs in a way that was agreed by them as suitable. Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 15 The manager informed the inspector that the District nurses currently only visit on request, as does the local GP. Each service users file examined had information recorded on charts that promote skin care. The medication system was checked during this inspection and found to be well recorded and documented. All polices and procedures held at the home are updated and include the safe recording and administration of medication. 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 used. The manager has also completed her “Management of Medicines” course with the Alliance Pharmacist and will promote the home policies and procedures. One service user stated that they administer their own medication. This is done with staff support. This promotes independence and will assist them when this service user moves into the local community on their own. Stepping Stones DS0000003560.V292656.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22/23 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The service users at Stepping Stones can be confident that their complaints or concerns will be listened to and acted upon. EVIDENCE: The home has a complaints procedure in place and has a designated complaints file. The relative feedback card stated that they were aware that there is a complaints procedure in place. At this time none had used the system to make a complaint. One complaint received by the home was from a service user. This complaint was well documented and showed in comprehensive details the actions taken and outcome as well as confirming that the timescale had been met. The service user said that they had agreed with the outcome and signed an agreement. All service users spoken with during this inspection confirmed that they would either talk to the manager or their facilitator if they had any concerns or complaints. Several service users confirmed that they felt that any complaints or concerns would be acted upon. One adult protection issue has been raised since the last inspection and the home had information on this incident as well as how the incident was dealt with. Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 17 This issue proved to be unfounded and the home’s Manager had dealt with this appropriately. Those staff files examined provided evidence of the necessary pre-employment checks being undertaken including Criminal Record Bureau Disclosures, ensuring as far as possible unsuitable staff are not employed. To further protect the service users the staff sign a yearly declaration to state there are no changes in this status. This assists the manager in the ongoing protection of the service users. Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24/30 Quality in this outcome area is good. This judgment 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 the service users 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 service users with level access throughout. These are automatically opening front doors and two-way bedroom doors. Areas inspected were found to be comfortable, well furnished and clean. All areas are assessable for wheelchair access and were bright and cheerful. The service users showed the inspector their bedrooms. All bedrooms were personalised and well decorated. Service users said that they were involved in choosing the colour scheme and personalising their bedroom. Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 19 The providers have installed the aids and adaptations (such as hand/grab rails, bath/mobile hoists and electric/manual wheelchairs) necessary 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 can be moved up and down, and recharging facilities for wheelchairs. The inspector found the home to be clean and free from offensive odours. The home has an infection control policy and all staff complete an infection control course. The Registered Manager is also a member of the local Infection control link group. Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32/33/34/35/36 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Ongoing staff training is encouraged enabling service users to receive the best possible service. EVIDENCE: 5 staff members were spoken with and 4 staff files examined during this inspection. It was clear from these files that the manager carries out staff appraisals and then produces a staff training and development plan for each individual staff member ensuring staff have clarity of their roles and responsibilities. The staff’s training files are divided up to include sessions on mandatory training, staff professional development and individual personal development, ensuring staff training is individual to met individual needs. The manager writes yearly training and development plans for all staff and plans the homes budget around meeting staff training needs. Certificates are available, on staff files, confirming courses already completed. These include First Aid, Manual Handling and Food Hygiene. Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 21 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 staffs training and development. The manager informed the inspector that the last month had been difficult due to staff holidays and staff sickness. The staff also confirmed this and stated that the home usually has sufficient staff on duty. One relative feedback card made comment about there not being sufficient staff on duty due to holiday and sickness. The manager is currently reviewing this with input from the placing authority. The home currently has 19 staff employed, 14 of whom have completed their NVQ at level 2 or above. 3 staff members are due to start their NVQ’s. The files of on 4 staff showed that each staff member had a staff contract containing the terms and conditions of employment. Staff are expected to promote equal opportunities and receive training to this end. Within the homes appraisal system records are available that evaluate the staffs competence of promoting equal opportunities within the service. All staff have a 6-month probation period. One of the files examined by the Inspector contained a probationary period review and evaluation. Thus recording the suitability of staff employed. All staff received induction training. A competed induction training package was seen by the Inspector. All staff confirmed that they receive regular supervision with their manager. Staff supervision records were available for inspection. Some staff had had appraisals. These appraisals monitor work performances and highlight staff training needs. Of the 4 staff surveys that were returned to the Commission after the completion of the site visit, one survey stated that they did not receive on the job supervision and did not have regular staff meetings. This survey also stated that the home has a “very good staff, most who are friendly, sensible and fair”. Another stated that they would like more staff and transport so service users can have more one to one time with staff. This staff member goes on to say what the service does really well is “looking after clients needs and sending staff on training courses”. One staff member said they would not change anything to improve the home and that the home does “training” well. Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 22 Another staff survey states that they “would like to receive more information from previous carers/service providers when a new service user moves in”. This staff member goes onto say that “Stepping Stones is a very well run home all care plans are kept up to date and I feel we provide a high standard of care”. The staff member then, under the any other comment section writes that the home has gone through many changes and that everyone has embraced these changes and worked to the best of their ability as a team. Stepping Stones DS0000003560.V292656.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37/39/42 Quality in this outcome area is good. This judgment 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. The staff team are highly thought off by the service users and all service users are happy and state their needs are met. EVIDENCE: The Registered Manager is a qualified nurse and has the Registered Managers award and continues with her own personal development by attending courses that assist staff training. This has included recent courses on Fire Marshall training, Risk Assessments-Principles & Practice, Management of Medicines and at present distance learning course on Tutor Support. Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 24 The manager is also a member of the local Infection Control group. This group promotes hygiene issues within care settings, and so Stepping Stones benefits from this contact. The relative feedback card stated that the manager is a hand’s on manager and always put the service users first. The service users meeting minutes were seen during this inspection and the service users spoken with confirmed they had attended. The manager has recently sent out questionnaires to service users with the objective of collecting views about the homes menu. The completed questionnaires by service users were seen and service users confirmed they had completed them either themselves or with staff support. This promotes service users involvement in the running of the home. The manager has recently written to all service users and relatives to inform them of team changes in the house. Each bungalow has a separate team and hold their own team meetings. The letter sent out also confirms the reshuffle of the day care services in the community and the in-house activities programme the manager is considering. 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. Gas and electrical appliances were being routinely serviced and checked. Good health and safety practices reduce any unreasonable risk that may affect residents or staff. One staff member has completed a course that enables them to carry out all necessary testing on all electrical appilances. All staff have completed manadatory training in fire safety, health and safety, food hygiene, manual handling and moving and first aid. 3 Senior and Relief Senior staff have First Aid at work certificates and 3 Senior Staff have Intermediate Food Safety certificates. The home has a “Cross Containination” checklist for all staff to carry out and weekly Health and Safety checklists that included First Aid boxes and water temperature and fire alarm testing. Good health and safety practices reduce any unreasonable risk, affecting residents or staff, to an acceptable level. A fire drill was carried out in one of the bungalows during the inspection. All staff and service users responsed appropriately. Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 25 Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 26 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 4 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 3 34 4 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 4 X 3 X X 3 X Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 27 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.V292656.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stepping Stones DS0000003560.V292656.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!