Inspection on 11/05/06 for The Drive

This inspection was carried out on 11th May 2006.

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

The Drive 25/01/06

The Drive 09/06/05

The Drive 19/12/04

The Drive 25/08/04

The Drive 04/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 The Drive 17 The Drive Sidcup Kent DA14 4ER Lead Inspector Sue Grindlay Unannounced Inspection 11th May 2006 09:30 The Drive DS0000006811.V311169.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 The Drive DS0000006811.V311169.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. The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Drive Address 17 The Drive Sidcup Kent DA14 4ER 020 8309 0440 020 8309 1532 thedriverh@aol.com 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) The Drive Care Homes Ltd ** Post Vacant *** Care Home 12 Category(ies) of Learning disability (11), Learning disability over registration, with number 65 years of age (1) of places The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. I place registered for service user category LD(E) for named service user only. 25th January 2006 Date of last inspection Brief Description of the Service: The Drive offers a permanent home for up to twelve adults who have a severe or profound learning disability with associated and complex needs. Complex needs include mobility needs, arising from sensory deprivation, communication needs or behaviour that challenges. The home is located in a residential area within walking distance of the local town and public transport. The Home has it’s own transport which is used to provide opportunities outside of the Home. Staff support is provided 24 hours a day. Opportunities for leisure and occupation are provided by the Home and some service users attend a day service provided by their sponsoring authority. This is determined by the assessment of need and in negotiation with the commissioning authority. The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection over seven and a half hours. The manager was present throughout the inspection, and her line manager, the Head of Care, was present for part of the day. Service users are mainly nonverbal, but were observed carrying out their usual activities. Four service user files and four staff files were looked at, three staff members and the music therapist were interviewed. Questionnaires were returned from five relatives, one G.P. and one care manager, and another care manager was spoken to on the telephone. A tour was made of the building. What the service does well: 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 Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 6 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 The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 7 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 and 3 The latest service user was admitted appropriately, though was unable to visit the Home beforehand. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection it was recommended that access to health services should be agreed with the funding authority prior to admission. The latest admission is a Bexley client this does not pertain. However, the service user was outside of the category for age. The assessment of need was undertaken by the manager and her line manager, and looked in detail at all the areas of need. The report matched need with response to need in a practical and clear way. For example, in the area of social need and communication, the report states, “As there would be 4/5 staff on duty on any given day the responsibility would be spread across the staff team equally to ensure a keen ear and appropriate response were given”. A letter to the care manager confirms that the client’s needs can be met. The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 8 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, and 8 Residents of the Drive are treated as individuals and their separate needs are acknowledged. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four service user records were looked at. These were tidy and apparently up to date, but there was no photograph of the resident and no service contract. It is a requirement that records held in respect of service users comply with Schedule 3 (Requirement 1). Service user records reflect the individual needs of the residents, and significant changes to their functioning. Staff spoken to were aware of these, and adapted their responses accordingly. One of the residents has shown some aggressive behaviour, and the manager said that she was working with staff to help them develop a more honest relationship with this resident, so that trust can be built. A behaviour monitoring form is helping staff to identify trigger points, and to modify their responses to maintain calm. A recent notification of an incident states, “talk down techniques and diversionary tactics used”. The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 9 Staff knew residents well, and were able to say what each liked to do. Within the capability of each resident, they are enabled to participate in the running of the Home, for example, some residents will assist with their laundry The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 10 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, 14, 15 and 17 The Drive provides opportunities for service users to take part in stimulating and enjoyable activities. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said that the Home now has access to resources in the London Borough of Bexley, so this is a big improvement in the provision of stimulating and constructive activities for residents. Staff who were spoken to talked about “making a difference”, “improving lives” and “giving them opportunities”. One resident enjoys college, and had certificates on his wall for swimming, arts and crafts, music and communication skills. Activities enjoyed by residents include swimming, trampolining and attending a sensory centre. One resident had been enrolled at a flower arranging class, and this shows that staff are responsive to individual needs and wishes. The Service User Guide makes much of the philosophy of community involvement, but only one staff member mentioned this aspect specifically. The staff member said that it was important to enable residents to have a ‘normal’ life, and for this reason they do not go out as a large group. One of the residents attends a local church. The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 11 At home residents like to sing or play music. The manager has changed the time for craft activities for between four and five o’clock in the afternoon, and this is a good time as many of the residents have returned from the day centre at this time. A little group was enjoying colouring and there was a ‘hum’ of activity around the table. Some residents had enjoyed a visit to the theatre to see “Saturday Night Fever”, and holidays for several small groups are being planned at Camber sands. On the day of the inspection, one resident was waiting patiently in the hallway for a visit to his mother for the weekend. Another resident had a chart in his room with magnetic discs showing when he was due to have a home visit. The manager said that she likes to keep in touch with relatives routinely, and not just when there is a cause for concern. This is good practice, and is likely to improve joint working long term. She is encouraging key workers to assume this responsibility also. All five relatives who responded to the questionnaire said that they were welcomed at the Home at any time, and could see their relative in private. They all also said that they were kept informed of important matters affecting their relative. This standard is exceeded. Menus for the last four weeks showed a range of meals such as beef burgers and salad or pasta and chicken. The residents sat down to eat together at 5.30p.m. The meal for that day was chicken korma and rice, which they ate with enthusiasm. There were no vegetables provided, but the staff member prepared an attractive bowl of chopped mixed fruit for dessert. Residents were seated around two large refectory tables in the dining room. The new chairs have not arrived. Some of the seats had been washed and were in the garden, so some residents were using plastic garden chairs. These are not very stable and could be hazardous in this situation. In addition the lighting in the dining room is very poor. There is little natural light, the woodwork is very dark and the bulbs are of a low density. It is recommended to improve the lighting in the dining room, to make eating there a more pleasant experience (Recommendation 1). The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 12 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 and 20 Personal and healthcare support is given according to the individual need. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home operates a key worker system. Service users are supported by staff to be as independent as they can be. They can receive additional specialist support and advice as needed from occupational therapists, speech therapists and community psychiatric nurses. Reflexology, aromatherapy and music therapy enrich their experiences and sometimes promote new skills. The music therapist said that a service user’s unsupported use of the strings on an instrument called a ‘zimbala’ indicated that the service user might also use her hand to feed herself, thus maintaining skills she still has. Feedback from the G.P. indicates that the Home works in partnership with the doctor, that staff demonstrate an understanding of the care needs of service users, and specialist advice is appropriately incorporated into the care plan. Referrals are made to specialist resources when required, for example one service user’s mobility has been re-assessed following the loss of an eye. Another service user has been referred to the psychologist for a baseline test, as he has begun to refuse to go out. Guidelines for the use of rectal diazepam were seen on one file. They had been completed by the Community learning The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 13 disability nurse and agreed by the G.P. but there were no signatures to endorse this, and it is recommended that signatures are obtained in these circumstances (Recommendation 2). The homely remedies list for each individual is signed by the G.P. It states the circumstances, dosage and frequency of administration. The medication profile for each resident includes a photograph, list of all medication taken and dosage, its purpose and possible side effects. This is useful information. The MAR sheets were loose in the folder, and could become displaced. It is recommended that they be secured in the folder to prevent errors (Recommendation 3). A sheet at the front of the folder gave sample signatures and initials for staff members, but not all staff had signed, and this is a further recommendation (Recommendation 4). The medicine trolley is kept in a walk in cupboard. The light in this room is extremely poor. It is recommended that if medication is either checked or administered in this room, the lighting is improved in order to prevent error (Recommendation 5). The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 14 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 and 23 There have been no complaints since the last inspection. However, several adult protection enquiries have raised concerns about the level of supervision at the Drive. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Drive has a complaints policy. Four out of five relatives who answered the questionnaire said that were aware of this, and three said that they had needed to make a complaint. Three out of five relatives said that they were satisfied with the care given, and one said that things were improving. In the last relative’s survey conducted by the Home, one parent said, “I have no cause for complaint. I’m sure if I did it would be acted on right away”. One care manager has expressed concern about what she perceives as lack of supervision at the Drive. This followed a vulnerable adult investigation into an incident of self-injurious behaviour. The particular resident is receiving a greater level of supervision as a result of this enquiry. The Home has a whistleblowing policy, and staff spoken to stated that they would report any unacceptable treatment of a service user. A record is kept of any valuables held, such as passports or birth certificates and these are kept in a safe. Visitors to the Home are not routinely asked to sign the visitors’ book, and at one point a visitor to the top floor was found in the Home on the first floor. It is recommended that staff be encouraged to challenge visitors, ensure they sign the visitors’ book, and are escorted whilst on the premises (Recommendation 6). The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 15 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, 26, 29 and 30 Some parts of the Home are quite dark and gloomy. There were some safety hazards present, and previous requirements had not been met. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home is spacious, and double doors lead out from the lounge into a large level garden, which is laid mainly to lawn. The ramp across the width of the door has not yet been built, despite it having been raised in the last inspection report and by the regulation 26 visitor on several occasions. This could present a stumbling hazard. One care manager considers that the building is too large to supervise residents, although residents can choose whether they wish to be alone or socialise. The kitchen units have not yet been replaced, although they are to be in place by the end of June. The manager said that the stair carpet also is to be replaced once the Head office moves out of the building. This will also give the residents another large room at the top of the house. Holes have been cut in the radiator covers to enable the controls to be accessed so that thermostats can be altered according to need. Dark wood in the lounge, hall and dining room give a rather gloomy feel to the Home. Panels of plywood propped against the laundry wall were removed during the course of the The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 16 inspection. It was noted that the yard area outside the kitchen door still has discarded items, which should be removed (Recommendation 6). Bedrooms seen were of a good size, were bright and cheerful, nicely decorated and personalised with service users’ own items. A loose rug in one bedroom had a curled corner, which could present a tripping hazard, and this was discussed with the manager at the time of the visit. Some service users had family photographs and certificates of attainment on the wall. A lift is available to access the upper floors. A child safety gate was in place on a downstairs corridor, and this is inappropriate given the age of the residents. The manager said it was to be replaced. Other equipment is available as required. One resident had a waterbed and an air purifier. Some sensory equipment was in place. The Home was clean, hygienic and free from odours on the day of the inspection. The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 17 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 and 35 The manager is working towards a full staffing complement, and in establishing a competent and skilled workforce. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was noted in the last inspection that the Home had not met the Department of Health’s target for 50 of care staff to achieve a vocational qualification in care by December 2005. Two staff members have the NVQ2 and one is currently doing the NVQ3. The manager is applying for funding to enable four more staff to access this training. She is proposing to revise the key worker system to create batter matching for residents, and plans to do this through discussion in supervision. Staff spoken to on the day of the inspection were interested in their work and had some understanding of the philosophy of care in the Home, although they were unable to mention the five key areas specifically. Comments around this tended to be things like, “giving them whatever you can do for them”, or “improve the lives of residents”. It is recommended that these five key areas are used as a training tool, perhaps focussing on one at a time in team meetings, to promote discussion and staff development (Recommendation 7). A photo board in the hallway enables residents to see who is on shift that day. One visiting professional said, “I think the quality of care is good. Staff interact sympathetically and are caring”. The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 18 The Home has an establishment of ten permanent care staff and four vacancies, but two new staff have been appointed and are waiting to start. The manager said that they have a strong bank staff backup, and this gives consistency to the care received by the residents. The manager has initiated staff meetings, and sees these as important to reinforce the idea of team working. Four out of five relatives who responded to the questionnaire said that there were always sufficient members of staff on duty. Staff have undertaken training in fire awareness (five staff), basic first aid (three staff), food hygiene, administration of medication, moving and handling, adult protection, health and safety and autism. All ten permanent staff hold a current first aid certificate. Some certificates were seen to evidence this training. Future training planned includes challenging behaviour, infection control, needs of the older adult and cerebral palsy. The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 19 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, 38, 39, and 42 The manager is trying to raise standards in the Home for the benefit and well being of the service users. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post for several months, but is not yet registered with the Commission. However, under the new procedures, the criminal records bureau check must be received before the application can be processed, and it is understood that this has now been applied for. The manager is hoping to complete her registered managers’ award at the end of this year. The Home’s strapline on its literature is, “creative care for people with learning disabilities”. The manager explained that they offer experiences using the senses as a communication tool. Books, DVDs, music and craft work are all seen as ways to engage with service users and allow them freedom of expression. The music therapist endorsed this, saying that staff notice changes The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 20 in residents with the passage of time, and the music therapy, which is tailored to each client, is “seen to be beneficial”. The manager’s own vision is key to the success of this philosophy, and staff spoke positively about the changes she has made across the board, the improvements in interaction between staff and residents, and her open and nurturing approach to the residents. She says that she likes to spend time with service users, talk to staff and engage with practical aspects of care such as feeding. When one staff member approached a resident from behind, and unceremoniously wiped his face, she took the staff member to one side to explain why it was not a good way to approach the client. She said that she likes to take time to tell staff what she wants, and is keen to promote creativity amongst the staff, as for example the introduction of a jangly bracelet to distract one service user from putting his hand up to his mouth whilst eating. She also comes in at the weekend or during holiday periods. This hands-on approach, as well as the positive ‘modelling’ that was observed going on throughout the day, is likely to impinge on staff and ultimately to enhance their practice. This standard is exceeded. One care manager commended the manager for good communication over the care of one of the residents. Regulation 26 reports are done regularly and copies are sent to the Commission. The manager said that staff read the reports and comments are fed back to Head Office. The reports are detailed, sometimes humorous, and give a vivid picture of what it is like to live and work in the Home. The provider uses a quality assurance system called ISO9001 but this was not inspected. The manager said in the action plan to the previous inspection report that she is monitoring recording systems on a weekly basis, and is compiling a checklist to record the information. This was seen at the inspection and is very comprehensive. It was suggested that not every check could be done each week, as this makes the task rather onerous, and the manager said she would review the frequency of the checks and do them on a rolling programme. Particular attention was given to safety aspects on the site visit because of regulation 26 report observations, and comments in the last inspection report. It was noted on this occasion that the shed was securely padlocked, as was the side gate. The garden appeared to be secure and safe. The employers’ liability insurance certificate was seen to be current up to 29/1/07. The lift was serviced in 9/05, the baths on 3/5/06. A fire drill had been conducted on 17/4/06, the fire alarm service was completed on 3/4/06 and fire extinguishers had been inspected in August last year. This had recorded the names of all residents and staff, time taken to evacuate the building, and any noncompliance, including action taken as a result. Portable appliance testing had been carried out in March. The regulation 26 report writer had commented on a dead tree to the side of the house. This is actually on the pavement, although if it fell it would certainly land on the drive of the Home. The manager said that this had been reported to the council who were responsible for this matter. Two safety matters already listed under standard 24, the boards propped in the laundry and the COSHH cupboard left unlocked, were also The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 21 highlighted in the regulation 26 report of December 2005. The report writer spelt out the safety implications, but the same situation pertained at the time of the site visit in May. This is now subject to a requirement (Requirement 2). The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 22 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 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 x 28 x 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 x 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 4 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 4 3 3 X 1 x The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 23 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 YA6 Regulation 17(1)(a) Requirement The Registered Person must maintian in respoect of each service user a record that includes the information, documents and other records specified in Schedule 3 relating to the service user. Timescale for action 14/07/06 2. YA42 13(4)(a) The Registered Person must 14/07/06 ensure that all parts of the hOme to which service users have access are so far as reasonably Practicable free from hazards to their safety. 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 YA17 Good Practice Recommendations It is recommended that the lighting be improved in the dining room, to make mealtimes a more pleasant experience. It is recommended that where a medical practitioner has endorsed the use of invasive treatment, the guidelines should be signed and updated by that person. DS0000006811.V311169.R01.S.doc Version 5.2 Page 24 2. YA19 The Drive The Drive DS0000006811.V311169.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 The Drive DS0000006811.V311169.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. 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!