Inspection on 19/12/07 for Stretton Edge Respite Unit

This inspection was carried out on 19th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 Stretton Edge Respite Unit 2 Hillfield Lane Stretton Burton upon Trent Staffordshire DE13 0BW Lead Inspector Mandy Brassington Key Unannounced Inspection 19th December 2007 11:00 Stretton Edge Respite Unit DS0000070169.V351389.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 Stretton Edge Respite Unit DS0000070169.V351389.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. Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stretton Edge Respite Unit Address 2 Hillfield Lane Stretton Burton upon Trent Staffordshire DE13 0BW 01782 598 008 01283 512 527 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) www.lifeways.co.uk Lifeways Community Care Ltd Deborah Irene Devitt Care Home 7 Category(ies) of Learning disability (7), Physical disability (1) registration, with number of places Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care (without nursing) and accommodation for service users whose primary care needs on admission to the home are within the following categories: Learning Disability (LD) 7 Physical Disability (PD) 1 The maximum number of service users to be accommodated is 7. One service user may be accommodated whose primary care needs on admission to the home are Learning Disability who also has a Physical Disability. New Service 2. 3. Date of last inspection Brief Description of the Service: Stretton Edge Respite Unit is operated by Lifeways Community Care Limited. The service was previously managed by South Staffordshire NHS Trust. Lifeways became the new service provider in June 2006. Previous arrangements for each person using the service were not disrupted and continued with the same frequency. The home provides a respite and day care service and is registered to accommodate seven adults with a learning disability, one of whom may have a physical disability. One emergency bed is available. The home enables both people who use the service and their carers to have a planned break. People are able to continue their usual pattern of care, attending day service provision and any planned social activities. A range of activities is planned in the community during each stay in line with people’s preferences and needs. The home is located in a residential area of Burton upon Trent within close proximity to local shops and services. There are a main public transport links near to the home. The two-storey property was originally two semi-detached staff houses, which have been adapted to provide a domestic-style unit comprising of seven single occupancy bedrooms, one of which is on the ground floor. The ground floor room and bathroom are able to accommodate people with a physical disability with suitable moving and handling equipment. Ramp access is provided to all external entrances and there is an enclosed garden to the rear of the property. The home provides people who use the service information about the home within the Statement of Purpose and Service User Guide. The Statement of Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 5 Purpose records that the fee level for the home is £20 per night, £132 per week. Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered the core standards. The inspection took place over 6 hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. Prior to the inspection the manager had completed an Annual Quality Assurance Audit (AQAA) for the Commission for Social Care Inspection. Two completed questionnaires were returned from relatives. A tour of the home was undertaken. On the day of the inspection, the home was accommodating five people. The inspection included an examination of records, indirect observation, discussion and observation of people who use the service, and staff on duty. Three Plans of care were examined along with three staff records. Observation of daily events took place. Inspection of the storage system, and medication procedures were inspected. Three requirements and one recommendation were made as a result of this visit. What the service does well: An assessment of need is carried out prior to people entering the home, and the manager assesses whether the home is able to accommodate the person. From the assessment, a plan is developed with the individual and where appropriate, their representative. People are able to have a slow introduction to the home at a pace to suit each individual. There are no restrictions placed on the number of day or meal visits prior to staying in the home. The service is managed to enable people to have a consistent pattern of care and continue with usual activities. Whilst staying in the home people also have opportunities to develop life skills and participate in different activities. There is a stable group of staff, with many staff having worked at the home of a significant length of time. Through training and experience the staff team have a balance of skills, knowledge and experience to meet the individual needs of people who use the service, and have developed good relationships with individuals. The people who used the service spoke positively about the staff team. Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 7 Staff support people to retain living skills and people can participate in daily household tasks, including domestic duties and cooking. Staff give sensitive support where required to assist individual activities. There are robust medication systems in place and the staff demonstrated excellent knowledge of medication systems and knowledge of drug useage. A full audit of all medicines is maintained and appropriate checks carried out to ensure at each stay people are receiving the correct medicines. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stretton Edge Respite Unit DS0000070169.V351389.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 Stretton Edge Respite Unit DS0000070169.V351389.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to the home only take place after a comprehensive assessment. People are able to spend time in the home prior to deciding whether to receive respite. The Statement of Purpose does not accurately reflect the service provided in the home in relation to day care provision, and support in the community. EVIDENCE: The new service provider has developed a Statement of Purpose and Service User Guide, which included pictorial symbols to support understanding. The Guide included details of fees, along with what a person can expect and support provided from the service. The Statement of Purpose does not clearly reflect whom the home is able to support, in line with the registration of the service. The Guide needs to be reviewed to reflect the home is able to accommodate people whose primary need is learning disability and for one person who has a physical disability. Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 10 The home also provides day care for one person on one day a week. There is no reference to the provision of day care within the Guide. This is to be included to reflect the service provided. The Statement of Purpose records that the service may provide support to be in their own homes. This was discussed with the manager, who reported that this service is due to start in the New Year. The service is registered to provide care and accommodation as a registered care home, provision of care within the person’s own home is not included in the registration. Staff providing this care in a person’s home would constitute an offence under the Care Standards Act 2000. The manager agreed that this service would not be provided from the home. The Statement of Purpose is to be reviewed to reflect the current service provided. People are able to visit the home prior to choosing to receive a service. Discussion with the manager and inspection of records revealed that the manager or deputy would carry out an assessment to ensure the home could support the person. Introduction to the home was at a pace to suit the individual. Documentation relating to one new referral was inspected and revealed that the person had visited the home on four occasions to spend time with staff and other people. No overnight stays had taken place. Each person had a contract and the manager agrees with the placing authority the number of nights accommodation to provided on an annual basis. Stretton Edge Respite Unit DS0000070169.V351389.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. 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. The plan is person centred and focuses on the person’s individual support and personal preferences. Information is shared with the individual and is regularly reviewed. EVIDENCE: The Annual Quality Assurance Audit reported that the home has a comprehensive support package, which covers all aspects of personal, social and health care needs, including assessments of risk. Three plans of care were inspected which confirmed this. Each plan included personal information, support needs with step by step guidance to follow to ensure consistency, and assessments of risk for identified concerns including road safety, support in the community, bathing, financial awareness and management of complex behaviour. Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 12 Each person had a ‘My Health Check and Action Plan’ from South Staffordshire Care Trust. On the day of the inspection, a Community Nurse, who supports and monitors health needs of people receiving respite, visited the home to ensure people were receiving appropriate support. One plan included specific details around the support required in relation to moving and handling, sleep pattern and sleeping position. Guidance from the Medicines and Healthcare Products Regulatory Agency (MHRA) was included in the plan. People using the service receive respite according to need and agreed funding. Staff reported that most people have a regular pattern of care. A small number of people use the service at short notice. Due to the length of time between stays the plans of care are reviewed during each period of respite care. Staff stated the plans are written and reviewed by senior staff in conjunction with people who use the service and their representatives. A formal annual review is conducted as part of the single assessment process. Stretton Edge Respite Unit DS0000070169.V351389.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): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to enjoy a stimulating lifestyle with a variety of options to choose from. Routines are very flexible and people can make choices in all areas of their life. Personal relationships are encouraged and people are able to develop and maintain relationships. EVIDENCE: Discussion with individuals revealed that they were able to choose to go to places of interest, and staff are flexible to enable activities where support is required to take place. The home no longer has a car; staff reported that public transport and taxi’s are used and coaches for longer journeys. Over the past months there have been opportunities for people to participate in trips to Grassington, Matlock, and Blackpool. Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 14 Where possible individuals are able to receive respite with friends and the same familiar people. People continue to attend day services and regular social events and during the week activities focus on the local area. People who used the service said ‘ it’s good to go places with my friends, I like going out here’. One person confirmed, ‘I like staying here with my friends, we come here together.’ From discussion with the manager and staff, it was evident the team are committed to ensuring that people who use the service are able to live an ordinary life, and have access to all community facilities and services. On the day of the inspection, there were four people already receiving respite care and one person arriving on that day. In the evening three people chose to go to the cinema and have their evening meal at a restaurant, and two people chose to stay at the home. Staff were observed speaking clearly to individuals and giving people information to enable a choice to be made. Staff demonstrated a good knowledge of individuals needs and preferences to support the decision making process. Staff reported that the home is able to meet people’s diverse cultural needs in relation to diet, religion and individual needs. The home accommodates people from different ethnicity groups, reflecting the demographics of the local area. Staff reported all people’s individual needs are assessed to ensure staff have suitable knowledge to provide a good quality service. People can maintain contact with friends and family during their stay and the plan of care records people usual routine and activities. Where possible, the staff reported they continue the same pattern of care including planned activities and clubs. One person commented, ‘you get to do different things here, and get to go out a lot.’ Meals are prepared according to individual requests. People who use the service are included in purchasing and choosing food, and preparation of meals. People receiving a service commented ‘I like cooking, making Sunday diners and jam tarts’, ‘I can do my own snacks’. Stretton Edge Respite Unit DS0000070169.V351389.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 good. This judgement has been made using available evidence including a visit to this service. People who use service continue to have access to healthcare services during the respite stay, and plans of care record health care needs. The home has a robust medication policy supported by procedures, practice and guidance for staff. EVIDENCE: The Annual Quality Assurance Audit completed by the manager, reported that health needs are recorded and reviewed regularly within a multi-disciplinary approach to ensure each individual is supported appropriately. The plans of care inspected confirmed individual’s health needs were recorded, and there was evidence of review. The service provides respite care for the individual, and therefore the person with their family, continues to take the lead role in relation to health care. Each person had a ‘My Health Check and Action Plan’ from South Staffordshire Care trust. On the day of the inspection, a Community Nurse, who supports Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 16 and monitors health needs of people receiving respite visited the home to ensure people were receiving appropriate support. One person had a pain profile, which included how pain was expressed, pain and discomfort associated with a particular diagnosed disease and management of pain. Where people live within the local area, the person’s General practitioner continues to be used. For people staying a distance away from home, the service is able to register people at a local Practice. Each plan of care includes a list of medication for the person. At each stay a copy of the persons prescription are obtained, and this is checked to ensure there are no changes. Where any change has been noted, the General Practitioner is contacted to confirm details of the medication to be administered. One Doctor has a contract with the home and writes all Medication Administration Records. An audit of medicines received and leaving the home was maintained. Details of staff who have completed the training for safe administration of medication was maintained, and discussion with staff revealed a good knowledge of medicines, policies and procedures. Staff have also received training for administering rectal diazepam and nasal Midozolam. Staff reported this training was taken on a voluntary basis and where there are no trained staff available, the emergency services would be contacted. The medication procedures and knowledge of staff means that people can be confident that medication is administered safely. Stretton Edge Respite Unit DS0000070169.V351389.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 service has a complaints procedure that is clearly written and is supplied to everyone living at the home. The staff understand the procedures for Safeguarding Adults and have a good knowledge of procedures and how to respond to an alert. EVIDENCE: The home has a Company complaints procedure that is clearly written and easy to understand. The complaints procedure was included within the Service User Guide. Individuals are encouraged to raise any concerns and a record of concerns and complaints are maintained. There have been no complaints received by CSCI since the last inspection. The induction for staff includes safeguarding adults and the manager reported that this training is on-going for all persons working in the home. There has been one safeguarding referral since the last inspection. Discussion with the manager revealed that she was clear regarding the agreed protocols and recording of the incident, and liaised appropriately with external agencies. Discussion with staff revealed they were clear on how to respond to an alert. Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 18 Inspection of personal finances of people whose records were inspected, revealed the home had robust recording systems in place and monies were accurately recorded. Stretton Edge Respite Unit DS0000070169.V351389.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, 25, 27, 28, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use services are encouraged to see the home as their own during their stay. The home is a safe place to live and people are able to bring in personal possessions during their stay. The kitchen is not accessible to all people with a physical disability. EVIDENCE: The home is two former local authority staff homes, which were converted for their current use. A door connects the ground floor, though the first floor bedrooms remain separate and are accessed by two staircases at each end of the home. On the ground floor, there is one bedroom and bathroom adapted for the needs of people with a physical disability. The home has two lounge dining areas and a small kitchen. Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 20 The shared space is satisfactory for this number of people though the kitchen is not accessible for people who use mobility aids or moving equipment. Staff involve people in the preparation of food in the dinning areas. Each lounge has a television and one room has electronic games equipment. It is recommended that the lounge and dining areas be redecorated as it has been marked and damaged in areas from mobility equipment. The bedrooms contain adequate furniture and are plainly decorated to enable service users to personalise the rooms during their respite stay. Staff reported that where possible people of the same gender stay in rooms off the same corridor. There are two first floor bathrooms, one on each side of the home. The baths have been fitted with thermostatic valves to regulate the temperature. The temperature was recorded as 37 degrees. Staff confirmed that this was cool. It is required that bathing water be at a suitable temperature of around 43 degrees to ensure people’s safety and comfort. Stretton Edge Respite Unit DS0000070169.V351389.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a good recruitment procedure to ensure that people are not placed at risk. Staff receive an induction to the service and on-going training to have suitable skills to provide a good quality service. EVIDENCE: On the day of the inspection, the manager was working in a supernumerary capacity. Support staff on duty consisted of:2 Support staff working from 7.15am – 2.45pm and 3.15pm 2 Support staff working from 2.00pm – 9.30pm 1 Support staff working from 3.30pm – 11.00pm, and completing a sleep in shift. 1 Night support staff working 8.50pm – 7.30am. The staff support on each shift may vary, due to the number of people receiving respite care and the individual’s needs. Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 22 People who used the service and responses from relatives within completed questionnaires, spoke positively about all members of the staff team and reported, ‘the staff listen to what you’re saying’, ‘we can choose what we are doing’. Three staff records were inspected and demonstrated the organisation has robust recruitment practices. All records included a photograph, an application form, two written references, a Protection of Vulnerable Adults (PoVA first) check and details of a Criminal Records Bureau Check (CRB). Discussion with one member of staff revealed they were able to work in a supernumerary capacity at the beginning of their induction, and the person was working through a comprehensive six-month induction and training package. The induction included record keeping, medication, finances, personal safety, and mandatory training. Discussion with staff and inspection of records revealed that people have attended training for Health and Safety, Moving and Handling, Safe administration of Medication, and Personal safety and Conflict resolution. Each person has a Personal development plan which is completed with the manager. Discussion with staff demonstrated people have a commitment to providing a good quality service, and a good knowledge of individual’s needs and how to support people. The staff team have continued to work closely together to ensure the home has provided a consistent support during the transition from the Health Care Trust to Lifeways Community Care. Stretton Edge Respite Unit DS0000070169.V351389.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 manager has a clear understanding of the key principles and focus of the service and is person centred in her approach. People who use the service benefit from a professional management approach, whereby staff skills are promoted and personal achievements recognised. EVIDENCE: It is evident from observation and discussion with staff, that the manager is extremely enthusiastic and committed to promoting people’s rights and providing a quality service. Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 24 The manager is person-centred in her approach and is open and transparent in all areas of managing the home. The manager’s skills, knowledge and practice have resulted in a consistent service being provided during and after the transition to Lifeways Community Care. Staff commented they feel valued and part of a supportive team and would have no hesitation approaching the manager or senior staff, who are supportive and recognises personal achievement. Prior to the Inspection the Registered manager completed an Annual Quality Assurance Audit (AQAA) for the Commission for Social Care Inspection. The AQAA was completed to a good standard and related to the National Minimum Standards for each outcome area. Evidence within the AQAA was sampled and found to be accurate. Inspection of fire records demonstrated that weekly fire checks are completed and fire equipment is suitably maintained. It is required that the Emergency lights be tested monthly, the last recorded test was July 2007. Portable appliance testing had been completed in June 2007. Stretton Edge Respite Unit DS0000070169.V351389.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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 X 4 X 3 X X 2 X Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 (1)(b) Requirement The Statement of Purpose must reflect the service provided in line with the registration of the home, including day care provision Bathing water within the home must be assessed for the risk they present to the people that use the service and action taken to minimise any identified risk whilst ensuring people are also able to bathe at a safe warm temperature. Emergency lighting equipment must be tested each month to ensure the equipment is in good working order, to protect people who use the service. Timescale for action 19/02/08 2 YA27 13 (4) 19/01/08 3 YA43 23 (4)(c)(v) 19/01/08 Stretton Edge Respite Unit DS0000070169.V351389.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. 1 Refer to Standard YA24 Good Practice Recommendations Due to damage caused from mobility equipment, to decorate the lounge to a good standard Stretton Edge Respite Unit DS0000070169.V351389.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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