Inspection on 28/02/07 for Sylvan Road (16)

This inspection was carried out on 28th February 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sylvan Road (16) 23/02/06

Sylvan Road (16) 13/09/05

Sylvan Road (16) 21/02/05

Sylvan Road (16) 14/09/04

Sylvan Road (16) 15/03/04

Sylvan Road (16) 08/03/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Sylvan Road (16) 16 Sylvan Road Wanstead London E11 1QM Lead Inspector Jackie Date Key Unannounced Inspection 28th February to 6th March 2007 1:30 DS0000025929.V331681.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 DS0000025929.V331681.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. DS0000025929.V331681.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sylvan Road (16) Address 16 Sylvan Road Wanstead London E11 1QM 020 8518 8004 020 8618 8004 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.rchl.org.uk Redbridge Community Housing Limited [RCHL] Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places DS0000025929.V331681.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 3 named people over 65 years. Date of last inspection 23rd February 2006 Brief Description of the Service: Sylvan Road is a home for six people with mental health problems. It is one of a number of homes run by RCHL, Redbridge Community Housing Ltd. The house is in Wanstead in the London Borough of Redbridge. The ground floor has a bedroom with a shower, a lounge, dining area, kitchen and conservatory. The conservatory has a smoking and non-smoking sitting area and there is also a garden. Upstairs there are four single bedrooms and a bathroom. The home is near to bus stops and the train station. There are shops close by. Most of the residents have lived together for a long time. None of the residents go to regular day services but they do go to clubs and can go out on their own and go where they want to go. The staff also organise some trips. Since the last inspection one of the residents has moved to a nursing home. As a result of this the previously double room is now being used as a single room and therefore there are now five residents living at the home. The basic charge per week for each service user is £742-50. The Director of Finance provided this information during the course of the second visit. Information about the service provided is contained in the service users guide. DS0000025929.V331681.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit lasted for about four hours and took place during the afternoon. A second shorter visit was made to talk check staff files. The staff and the residents were spoken to. All of the shared areas and three of the bedrooms were seen. Staff, care and other records were checked. Staff were asked about the care that residents receive, and were also observed carrying out their duties. Relatives were contacted and asked for their opinions of the service. Feedback was received from the relatives of two of the five residents. This was a key inspection and all of the key inspection standards were tested. What the service does well: What has improved since the last inspection? The organisation has looked at all of their staff records and made sure that all of the required checks have been made on staff in post. They have also made their recruitment procedure better. This will help to keep residents safe. Residents are now running their own meetings and taking the minutes. The communal areas have been redecorated and look much better. The building had a deep clean last year and this makes it easier for residents to keep it clean. DS0000025929.V331681.R01.S.doc Version 5.2 Page 6 Residents have been involved in staff interviews. 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. DS0000025929.V331681.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 DS0000025929.V331681.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 4 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Information is available to enable the staff team to meet residents’ needs. If a vacancy arose the required information would be gathered on a prospective resident and they and their relatives could spend time in the home to find out what it would be like to live there and to enable the resident to make a choice about living in the home, within their capacity to do so. EVIDENCE: There have not been any new admissions for several years. The organisation has an admissions procedure that includes gathering of information and assessments. It also contains details of how a prospective resident would be introduced to the home. The staff would be able to assess and introduce a new resident to the home if needed. Each resident has a care plan that contains information about what they can do, their likes and dislikes and what help and support they need. The staff team know residents well and know what they can do, their likes and dislikes and what help and support they need to meet these needs. DS0000025929.V331681.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ plans focus on their individual needs and abilities and contain detailed information so that staff can meet their needs safely. Residents’ needs are reviewed regularly and care plans and risk assessments updated when needed. The care plans of the older residents are reviewed more regularly as a matter of good practice and this exceeds minimum standards. Residents are encouraged and supported to be involved in decisions about what they do and what happens in the home. This includes staff recruitment and the development of the organisations business plan and this exceeds minimum standards. EVIDENCE: Each resident has a detailed care plan which takes into consideration the personal, health care and social support needs of the residents. Each resident has a six monthly review with other professionals as part of the Care DS0000025929.V331681.R01.S.doc Version 5.2 Page 10 Programme Approach (CPA). Changes are made to care plans after these reviews if necessary. Residents are involved with these reviews and with writing their care plans. The care plans of residents over the age of 65 are reviewed monthly and this ensures that the staff team always have current information to work to. This good practice is to be commended and exceeds minimum standards. Risk assessments relevant to each individual are made. For example one person specifically has risk assessments for spitting out medication and also for not responding to fire drills. The risk assessments are reviewed regularly and updated when needed. Overall sufficient detailed information is available so that staff can meet residents’ needs. Each resident also has a risk assessment in relation to his or her finances. Bankbooks are kept in the safe but all of the residents go to the bank independently to draw out money. When they return the amount that they have withdrawn is checked and recorded. Residents have lockable tins in their rooms to store cash. Residents are assisted to budget their money and are supported to be as independent as possible in this area. Residents’ meetings are held each week and a variety of topics are discussed. This includes everyday things like the menu and shopping and also changes in the home and plans for the future. Staff are present at the residents meetings but residents now “do their own meetings”. One resident said that he takes the minutes and writes the menu. Three of the residents attended training to enable them to participate in staff recruitment and have since been involved in interviewing staff. Two of the residents also participated in the development of the organisations business plan. These residents said that they enjoyed taking part. Staff spoken to said that the involvement of residents in decision-making has increased. Residents are consulted about all aspects of life in the home and make decisions about their lives. An independent advocate from the North East London Advocacy Service visits the home every six weeks to meet with the residents. This means that residents are given the opportunity to talk to an independent person about the home and about what they want to do. DS0000025929.V331681.R01.S.doc Version 5.2 Page 11 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): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to do as much as possible for themselves and to be independent. Residents go out when they want to and can keep in contact with their friends and families. The residents take part in a variety of activities and are part of the local community. Residents are given meals that they have chosen, like, and that meet their needs and individual preferences. EVIDENCE: Residents participate in household tasks on a rota basis. This includes the cooking as well as domestic chores. During the course of the visit residents were observed to make drinks when they wanted to. All of the residents are able to go out independently and can choose where they want to go. They are DS0000025929.V331681.R01.S.doc Version 5.2 Page 12 encouraged to do as much as they are able. For example residents go to the bank to collect their money. Residents said that they go to the cinema, the pub, out for meals, to church and to concerts. They all go to clubs on Mondays and Saturdays and some of them go to church on Sunday. On the first day of the inspection one of the residents had just returned from swimming. He said that he was really enjoying this and also that he had started to go to golf. Two of the residents now get support from an outreach worker. As stated previously one likes to go to golf the other likes to go shopping or to the cinema. Residents also went on holiday to Bognor in October. Residents said that they had a really good time there. Therefore the residents have the opportunity to do what they wish, to participate in activities and to be part of the local community. Residents’ families are welcome to visit and four of them have contact with their families. One resident goes home twice a week and his sister visits weekly, another resident’s brother visits fortnightly. Recently a resident moved to a nursing home and other residents have been to visit her. At the time of the visit one resident was talking about visiting again at Easter. Therefore residents are encouraged and if needed supported to keep in contact with their friends and relatives. As previously stated the residents discuss the menu at the weekly residents meeting. They then take turns to help with the cooking. One resident said that he was very good at making batter pudding and explained how he made it. Residents also help to get the main weekly shopping and during the week go out to get any extras. For example milk and bread. Residents also said that they like the food. Residents also help to clean the house and chores are shared out. Residents are encouraged to develop their skills. DS0000025929.V331681.R01.S.doc Version 5.2 Page 13 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 & 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. When required, residents receive personal care that meets their individual needs and preferences. The staff team administer medication appropriately but must ensure that for accountability any handwritten amendments or additions to Medication Administration Records (MAR) sheets are signed and dated by the person making the entry. Residents receive good support to ensure that they get the medical and health care that they need. The staff team are commended for the support that is given to residents in terms of their health care needs and this exceeds minimum standards. EVIDENCE: The residents are quite independent and require little support in terms of their personal care. The care plans contain details of the support needed. They also confirm that residents are encouraged to be as independent as possible. For example one care plan said that the resident can get in and out of the bath DS0000025929.V331681.R01.S.doc Version 5.2 Page 14 on his own but staff need to check the temperature and also ensure that the anti slip mat is in place. Some of the residents go to the doctor on their own and others are supported by the staff. One resident refuses to go to the dentist but the others visit a dentist in the community. Some of the residents go to a private chiropodist; others go to the NHS chiropodist. The residents now visit an optician in the community. Records are kept of medical appointments and outcomes. One of the residents has a serious life threatening illness and the staff team monitors this person’s condition. He is supported by his mother and by his key worker to attend appointments and discuss and decide on treatment. At present he is quite well. The staff team are going to receive training in relation palliative care as it is hoped that they will be able to support this resident to stay in the home when his condition deteriorates. As previously stated the care plans of older residents are reviewed more regularly to identify any additional needs they may have because of the ageing process and the resident who has a very serious illness is given the support that he needs. Residents’ files contained information on their, or their families, wishes in the event of death. The staff team are commended for the support that is given to residents in terms of their health care needs and this exceeds minimum standards. None of the residents self medicates and medication is administered by staff that have been trained to do this. Medication is securely stored in a locked cabinet in the office. In line with good practice the medication file has photographs of each resident and information about the medication that they take, how it is taken and possible side effects. Medication administration records are kept and are up-to-date. However there were some handwritten entries on the Medication Administration Records (MAR) sheets. For accountability any handwritten amendments or additions to Medication Administration Records (MAR) sheets must be signed and dated by the person making the entry. The pharmacist visits monthly to check medication and any issues identified are addressed. DS0000025929.V331681.R01.S.doc Version 5.2 Page 15 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. There is a complaints procedure that would be followed in the event of any complaints being made. Staff are aware of issues of abuse and work to protect residents from abuse. EVIDENCE: There is a complaints procedure and this is displayed in the home. Residents said that they could talk to staff if they werent happy about things. As stated previously an independent advocate visits the home every six weeks and residents could talk to this person as well. There have not been any recorded complaints since the last inspection. The organisation has produced a detailed adult protection policy that tells staff the actions to take in the event of abuse/suspected abuse being discovered. Staff spoken to were aware of the issues of abuse and aware of their responsibility to residents. When residents go out the staff usually check where they are going and when they expect to be back. Staff said that they know the usual pattern that each person has and if anything is different they will follow this up. All of the residents go to the bank or building society to sign for and withdraw their own cash. All of the residents keep their own cash but their bankbooks are kept in the safe. Records are kept of financial transactions and as part of this inspection the records and bankbooks were checked for two residents. In DS0000025929.V331681.R01.S.doc Version 5.2 Page 16 both cases the amount recorded in the book tallied with the records kept. The organisation carries out annual financial audits. Therefore systems are in place to ensure that residents are protected from financial abuse. DS0000025929.V331681.R01.S.doc Version 5.2 Page 17 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, 26, 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is suitable for their needs. However improvements are needed to the heating system so that residents can comfortably use their own private space whenever they choose to. EVIDENCE: The house is near to the local shops, bus routes and the tube station. The communal space consists of a lounge/diner, kitchen, conservatory, laundry room and a garden. The lounge diner is comfortable and has sky TV, video and a DVD player for the residents use. The conservatory has both smoking and no smoking areas and provides additional communal space and an area where residents can meet visitors in private if they want to. There are now five single bedrooms. The ground floor bedroom has an ensuite shower. The inspector visited two of the upstairs bedrooms and the ground floor bedroom. These bedrooms reflect individual likes and preferences and residents have DS0000025929.V331681.R01.S.doc Version 5.2 Page 18 previously confirmed that they chose the colours for their rooms. Since the last inspection the lounge, kitchen, hall, laundry and upstairs toilet have all been decorated and look much better. The residents therefore live in a home that is satisfactorily decorated. Unfortunately there are some on going problems with the conservatory. Cracks in the wall in the smoking room were plastered but have appeared again. The contractors that built the conservatory are still looking into the cause of this but once the problem has been resolved this area will also be decorated. In addition to the ensuite facility there is a bathroom on the first floor and three toilets around the home. None of the residents need any special aids and bathing and toilet facilities meet their needs. At the time of the last inspection the standards of cleanliness in the home were not satisfactory. Since then the home has had a thorough deep clean and this included carpets and furniture. A window cleaner now visits to clean the insides and outside of the windows. Residents do the day-to-day cleaning with support from the staff team and at the time of this visit the home appeared to be clean and hygienic. As at the time of the last inspection it is recommended that a deep clean be arranged periodically to ensure that the level of cleanliness is satisfactory. Residents can then continue to do the day-to-day cleaning with support from the staff team. The acting manager said that she hoped that this would be possible. A relative of one of the residents said that when she visits the upstairs is often cold and therefore it was not comfortable in her son’s room. She had been told that the upstairs heating had to be turned off during the day. This was discussed with the acting manager after the visit and she confirmed that the heating is not usually on upstairs during the day. The reason for this is that the heating system is old and cannot support the heating being on upstairs and downstairs at the same time. Therefore they tend to have the downstairs heating on during the day. She also said that this had been the situation for many years. This is not acceptable and must be addressed. All areas of the home must have appropriate and adequate heating so that it is comfortable for residents to use their own personal space at any time in addition to the communal areas. DS0000025929.V331681.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Commission for Social Care Inspection (CSCI) is now confident that residents are supported and protected by the organisations recruitment practice, including the recruitment of bank and agency staff. Staffing levels are sufficient, and staff receive the necessary training, supervision and support, in order to meet residents’ current needs and provide a good service for them. Residents are supported by a staff team that know them well and who are committed to providing a good quality service. EVIDENCE: Staff have job descriptions and in discussion were clear as to their individual role in the home. An inspection, at the organisations head office, of a sample of personnel files showed that the previous requirements with regards to staff recruitment and checks have now all been addressed. The organisation worked cooperatively with the Commission and reviewed their procedures and all of their staff files. They then took the necessary action to address any DS0000025929.V331681.R01.S.doc Version 5.2 Page 20 shortfalls and to ensure that the future recruitment procedure would be robust and would safeguard residents. A random sample of staff records were checked during the inspection and were found to contain the required information. At the time of the visit there were only four permanent staff in post. Two new staff have been recruited and are waiting for the necessary checks to be carried out. The other two posts need to be advertised. The vacancies are being covered in the main by relief staff. From examining the rota and from speaking to permanent and relief staff it was evident that regular relief staff are being used. It was also evident that they knew the residents and were very much part of the staff team. Relief staff attend staff meetings and also receive supervision from the acting manager. The acting manager has NVQ level 2 and 3 and another staff has almost completed NVQ 3. Of the two other permanent staff one has obtained NVQ level 2 and the other VRQ. Staff training records are kept and staff received appropriate training last year. This included food hygiene, mental health needs, fire safety and adult protection. Staff on duty confirmed that they receive regular supervision and good support from the acting manager. They also said that the staff are involved in what is happening in the home and looking at ways of improving the service. They were clear about their duties and responsibilities towards the residents and get the support and training that they need to provide an appropriate service to the residents. The two relatives spoken to said that they were happy with the service and the way in which the staff treat the residents. From Monday to Friday two staff are on duty from 8am to 8pm, on Saturdays there is only one member of staff on duty from 2.30pm and on Sundays from 3.30pm. At night there is one waking night staff. The times when one staff is on duty are when residents usually all go out. For example on Saturdays they go to a club between 1 p.m. and 7 p.m. This arrangement is flexible and staffing levels are sufficient to meet the assessed needs of the residents. DS0000025929.V331681.R01.S.doc Version 5.2 Page 21 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. Appropriate arrangements have been put in place for the management of the home during the absence of the registered manager. The home is appropriately managed and provides a safe environment for the residents. EVIDENCE: Last year the registered manager was seconded to another home run by the organisation. The senior support worker was appointed as acting manager during this period. This arrangement provided continuity and support to both staff and residents. The registered manager has since been appointed as manager at the other home and the vacancy was being advertised at the time DS0000025929.V331681.R01.S.doc Version 5.2 Page 22 of the visit. In the interim the acting manager continues to run the service. The acting manager has NVQ level 2 & 3 and experience of working with people with mental health needs. One member of staff said that they felt that the acting manager had “done a very good job”. The service to residents has continued to develop and to be of a good standard. Relief staff said that they felt valued members of the team and that their view and opinions were listened to. The home has been appropriately managed. The quality of the service provided to the residents is monitored by the acting manager and by the organisation. The service manager carries out monthly monitoring visits to assess how effectively the home is operating to meet its stated aims and objectives, and reports are written. These indicate the action to be taken when deficiencies are identified. Copies of these reports were available in the home and copies are sent to the Commission. In addition to this the organisation carries out a quality audit each year. All of the necessary health and safety checks are carried out and records are kept of these checks. A safe environment is provided for the residents. DS0000025929.V331681.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 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 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 3 3 X 3 X X 3 X DS0000025929.V331681.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 Requirement Timescale for action 30/04/07 2. YA24 23 For accountability any handwritten amendments or additions to Medication Administration Records (MAR) sheets must be signed and dated by the person making the entry. The heating system must be 30/06/07 repaired/upgraded to ensure that there is suitable heating to all parts of the building. 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 YA30 Good Practice Recommendations It is recommended that deep cleaning is carried out on a regular basis DS0000025929.V331681.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000025929.V331681.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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