Inspection on 15/09/08 for The Progress Project

This inspection was carried out on 15th September 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Progress Project 26/05/09

The Progress Project 26/02/08

The Progress Project 06/09/06

The Progress Project 31/01/06

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/11/2008.

CARE HOME ADULTS 18-65 The Progress Project 22 Winchester Road Worthing West Sussex BN11 4DH Lead Inspector Annie Taggart Unannounced Inspection 15th September 2008 10:00 The Progress Project DS0000064669.V371891.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 Progress Project DS0000064669.V371891.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 Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Progress Project Address 22 Winchester Road Worthing West Sussex BN11 4DH 01903 233390 01903 208857 vanessa@sunkistgroup.co.uk 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) Hemmingrod Ltd trading as The Progress Project Manager post vacant Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - (PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental disorder, excluding learning disability or dementia (MD). The maximum number of service users to be accommodated is 16. Date of last inspection 26th February 2008 Brief Description of the Service: The Progress Project is a care home registered to provide accommodation and personal care for up to sixteen residents with mental illnesses. Within this number residents with past or present alcohol and drug dependency may also be accommodated. The home is a detached two-storey property, which has been adapted and extended for its current use. The care home is situated in a residential area of Worthing, local shops and other amenities are within walking distance. Communal facilities include two lounges and dining room located on the ground floor. Private accommodation consists of seventeen single bedrooms and is located on the ground and first floors. There is ramp access into the care home. However, access to the first floor is via two staircases. There is a patio garden to the front of the premises and a courtyard to the rear, which are available for residents to use. The service is privately owned by Hemmingrod Ltd, trading as The Progress Project and the Responsible Individual is Mr. B. Schiavone. Current fees are from £795 per week The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home is subject to enforcement action and therefore there are no quality ratings in this report. A Notice of Proposal to Cancel the home’s registration was served on 12th June 2008, this was adopted by the Commission on 24/8/08 and A Notice to Cancel the Registration of the Progress Project was served. Hemmingrod Ltd have lodged an appeal to the Care Standards Tribunal under section 21 of the Care standards Act 2000. In order to plan for this unannounced visit, an Annual Quality Assurance Assessment (AQAA) was sent to the manager for completion and satisfaction surveys were sent to service users and healthcare professionals involved with the home. The AQAA was returned when it was due and contained good information about the services on offer in the home. Six service user and four staff surveys were returned and all made positive comments about the care and support currently being provided. Comments from surveys have been used in this report. No surveys were returned from healthcare professionals. The unannounced inspection was carried out on 21st July 2008 and lasted for 5.5 hours. During the visit we spent time talking to service users both in communal areas and in their private bedrooms and we spoke to the staff on duty and observed staff practice and interactions with service users. We also spoke to a care manager for one service user, who was visiting the home. We tracked four care plans and all supporting documents such as daily records and health plans and we spoke to the staff on duty and asked about how they were aware of the needs and wishes of the people they are supporting. We looked at five recruitment files, staff training files and evidence of supervision and we asked the staff about the training and support they receive. Records for the running of the business were seen and these included complaints and comments, incident and accident recording, health and safety records and the home’s insurance and registration certificate. The home is continuing to provide a service during the appeal made to the Care Standards Tribunal. As a result of this visit, five Requirements have been made. Timescales of 28 days have been made for these Requirements to be met so that the home can improve outcomes for the seven people still living there. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 6 The Manager was present and the responsible Individual Mr Schiavone was in the home for part of the visit and to receive feedback. What the service does well: What has improved since the last inspection? What they could do better: Care plans and risk assessment must be further developed to include behaviour management plans for the staff team to follow. Mandatory training must be updated for all staff where gaps are identified and training must be provided in the management of challenging behaviour. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 7 There must be improvements made to the environment in the home and plans agreed for service users to have increased support in keeping their rooms clean, safe and hygienic. Regulation 37 reports concerning any incidents or accidents that affect service users must be sent to the Commission as required and to ensure the safety of both service users and staff, the Registered Provider must consult with the Fire and Rescue Department to address training needs in fire training matters. 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. The Progress Project DS0000064669.V371891.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 The Progress Project DS0000064669.V371891.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 and 2 Information is available about the services on offer in the home but this needs to be reviewed and updated. There are people on the staff team who have the skills and training to carry out assessments for prospective service users. EVIDENCE: There is a Statement of Purpose and Service User Guide in place to inform people of the services on offer in the home. The documents were revised and updated in April 2008 but need to be further revised to reflect the recent changes in the staff team and the new address of the Commission. The manager said that she would address this. There is evidence in training records that there are members of staff employed in the home who have the skills and training to carry out assessments of needs for any prospective new service users. There have been no service users admitted since the last inspection visit. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 8 9 and 10 Although people have their needs and wishes recorded in a plan of care and are supported to make decisions about their future development, improvements are needed to care plans to include behaviour management plans. EVIDENCE: For each service user living in the home there is a detailed plan of care in place that guides the staff team to the assessed needs and wishes of each person. We tracked the care plans for four service users and found that they gave clear and concise information about the way people wish to be supported. The plans contain personal care preferences, access to the community, the personal and emotional support needed by people and also goals and objectives for future development have been discussed and agreed with service users. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 11 There was evidence that regular reviews are held with care managers and we saw that service users, families and other professionals involved in the support being offered to people had been involved in the care planning process. Service users told us that they were aware of their care plans and that they had a named key worker that works closely with them to ensure their needs and wishes are met. Risks assessments have been completed using a colour code system to identify the level of risk and how this can be managed. Although this system is successful in identifying the risks to service users and to other people, we spoke to the manager about how some assessments need to be extended to include an agreed management plan, especially for people who display difficult behaviours. For some people there are behaviour management plans in place that have been agreed and recorded with external professionals but for other people these have not been completed and the staff team have not all received challenging behaviour training. Records show us that the staff team deal with difficult behaviours on a regular basis. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 and 17 At this visit we saw that the people living in the home are being offered a range of activities, they have access to their local community and are involved in menu planning, shopping for food and cooking meals. EVIDENCE: From looking at daily records and talking to service users we saw that people are involved in a range of activities and outings. For each person living in the home there is an activities plan in place that forms part of the care plan and these are designed to aid people’s increasing independence and skills. We saw that people have access to their local community, one person had been out to the town for a walk, some people have their own bicycles to get around and in the group session that was being held people were discussing using trains and buses rather than the car to aid their health and independence. One person was just returning from a holiday and told us they had really enjoyed it and another person said they were taking driving lessons. We saw that some people attend the local MIND club and one person regularly goes to The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 13 the gym. Another service user told us that they had taken up photography and had been supported by the staff team to follow this hobby. There have been a number of groups set up within the home and these include the recovery group, social skills, newspapers and current affairs, music appreciation and drugs and alcohol misuse awareness. Although these groups are recorded in the weekly activities sheets we observed that not all service users choose to attend the groups and in the afternoon on the day of the visit two people attended the session. From looking at menus and talking to service users we saw that people are offered a variety of fresh, home cooked meals and we also saw that people also enjoy meals out and “takeaways”. Twice weekly there is a breakfast group where staff and service users sit together and as this was happening on the day of the visit we saw that people had a variety of fresh fruits, crumpets, tea cakes and drinks and sat together discussing issues concerning the home. There is also a “Food and Mood” group that discusses how certain food can have an effect on people’s moods and behaviours and also on diabetes sufferers and people are encouraged to follow healthy eating habits. We were told that the home no longer employs a cook and service users are involved in planning the menus, food shop and in the preparation of meals. We saw that people made their own breakfast and had access to snacks and drinks at any time. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 and 20 At the time of this visit we saw that the people living in the home currently have access to healthcare support for both their physical and emotional needs and medication is being well managed. EVIDENCE: From looking at care plans, daily records and talking to service users we saw that the people living in the home have access to good healthcare support. There is involvement with the local doctors surgery, community mental health teams, psychology and psychiatric services and people attend dental and opticians appointments. The home also employs a trained occupational therapist who has set up a number of groups including a “recovery” group where people can talk about their feelings and discuss areas concerning their physical and emotional wellbeing. At the present time records show us that the groups are not always being well attended and the person facilitating them said that they hoped that attendance would improve. The people living in the home said that they felt very well supported and a staff member told us, the new manager has now ensured that there is a good cohesive team that is focussed on client centred recovery”. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 15 The care manager for one person, who was visiting the home, told us that they were satisfied with the care currently being provided. At this visit we saw that there are processes in place for the storage and administration of medication and records show us that the staff administering medication receive training. For people who wish to self medicate there are agreed plans in place and there is a monitoring system to assess if this is being successful. We saw that recently the staff member on duty had noticed that one person was not taking their medication and a discussion with the service user led to an agreement being put in place where the person could still take their own medication but be observed by staff. Medication Administration Sheets (MAR) were completed and no gaps in signing were seen. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 At this visit we saw that although complaints and concerns are recorded and acted upon the complaints procedure needs to be updated. From looking at records we saw that he staff team have received safeguarding training. EVIDENCE: There is a complaints procedure in place, a copy of which is including in the Service User Guide and is also displayed in the home. The procedure needs to be updated to reflect the change in address of the Commission. The manager said that this would be done. There is also a “moans and grumbles” book in use for service users and we saw that concerns are addressed and the outcomes fed back to the person as soon as possible. People also have the opportunity to air their views at regular house meetings. A service user said, “ this new manager is very good and has made a lot of difference, if I have any complaints she listens and does something about it”. In the AQAA we were told that six complaints had been received in the last year and we saw that these had been investigated and outcomes fed back to complainants. The Commission have recently received a complaint from a neighbour regarding service users from the home and other people from the surrounding area, congregating in the front of the house and causing a nuisance, especially at weekends when the manager is not in the home. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 17 The manager acknowledged that there had been a number of complaints about antisocial behaviour and told us that she had spoken to the complainant and was addressing unacceptable behaviours with service users. There has been a safeguarding referral made about the home, investigated by the West Sussex Safeguarding Team leading to two referrals being made to the PoVA (Protection of Vulnerable Adults) list. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 28 and 30 Although the communal areas are comfortable and homely, there is a need for redecoration and refurbishment throughout the home and for service to have more support in keeping their bedrooms clean, safe and hygienic. EVIDENCE: The home is situated over two floors with a large lounge and dining area on the ground floor, there is also an activities/pool room to the rear of the building. There is a well-maintained front garden and an enclosed garden with tables and chairs to the rear. There was a cleaner working in the home and communal areas were clean and hygienic. Although the home is comfortable and had a homely feel there is a need for refurbishment and redecoration in most areas. The lounge although comfortable with modern furniture, is in need of redecoration, the kitchen is old and needs refurbishment, most communal The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 19 areas need updating and redecorating and toilets have old and worn floor coverings. The rear garden has a very uneven and broken concrete surface in some areas that is in need of attention as it could be a trip hazard. Service users bedrooms have been personalised with their own belongings and people have a key to their rooms. Service users told us that they looked after their own bedrooms with help from the staff team but we saw that two bedrooms were in an unacceptable state and were dirty and had belongings all over the floors and surfaces. We also saw that carpets were in need of replacing in some rooms and in one room the carpet near the bed was covered in cigarette burns. One service user chose not to show us their bedroom. Risk assessments are in place for people who wish to smoke in their rooms and notices are on doors saying that these are smoking rooms but we spoke to the manager about the need to review and update the assessments to ensure safety in the home. We spoke to a service user about the poor state of their room and they said that the staff team did help them with cleaning but they liked to do it themselves. We asked the manager to look at this bedroom with the service users and spoke to the manager about the need to re-assess and agree with people the support needed to keep their bedrooms at a safe level of hygiene, whilst still supporting their choice and independence. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35. Although the people living in the home are now being supported by a staff team that they describe as being competent and caring, there is a need for further mandatory and specialised training to take place to ensure that all of the staff team have the skills they need to safely support people. EVIDENCE: From looking at staffing rotas and observing the staff on duty we saw that during this visit there were sufficient numbers of staff on duty to support the seven people currently living in the home. There were four staff on duty during the morning shift and three during the afternoon. There was also a cleaning person on duty and the manager’s hours are in addition to the rota. There is now a robust recruitment process in place. We saw the recruitment files for five members of staff and all had the required documentation in place including a current Criminal Bureau Check (CRB) and two references. We saw that one of the staff team is a qualified occupational therapist and another staff member is a designated activities co-ordinator. In the AQAA we were told that no agency staff had been used for the past three months of the date up to the time the document was completed. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 21 We were told that home no longer employs a cook as it has been agreed that it more beneficial to peoples skills and independence that staff and service users plan and cook meals together and the cleaner has recently been employed. The people living in the home were complimentary about the staff team and comments included, “this place, (the home) has taken on a lot of change lately, I now get one to one help with my mental health issues and having lived in three other homes before, this is the one that is working out for me. The staff team are caring people who do their job properly” and from another person, “ they (the staff team) are really good, they are helping me with managing my independence and I am going to get my own flat”. Training records showed us that new staff receive an in-house induction and also an induction in line with Skills for Care guidelines. Training records show us that staff receive mandatory training such as first aid, health and safety and infection control. This mandatory training was out of date for some people and the manager told us that she was carrying out a training audit to identify gaps in training and would provide updates. In the AQAA we were told that four members of staff hold NVQ 2 or above and we saw that one person is a registered mental health nurse and others have previous experience in working with the client group. The Registered Provider told us that there are now two registered mental health nurses on the team. As we have discussed with the manager, the Statement of Purpose needs to be updated to reflect recent changes to the staff team. For some people courses such as understanding the Mental Capacity Act, Autism awareness and working with drug and alcohol abuse have been attended and records showed us that the new manager books away days to carry out staff training and support. The latest training recently recorded was professional boundaries and protecting people from abuse. We saw from incident and accident recording that the staff team deal with difficult behaviours on a regular basis but as yet not all of the staff have received training in managing challenging behaviour. The manager showed us a training plan that identified that this training needed to be provided for some people and told us that it was planned for the near future. We saw records that showed us that the staff team receive supervision and have regular team meetings. The occupational therapist told us that they receive both in-house supervision and professional supervision outside of the home. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 22 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 38 39 41 and 42 The Registered Providers have employed a manager who they have assessed as having the skills and competence to manager the home. At this visit we saw that improvements are needed to the management of the home by reporting Regulation 37 events to the Commission and to updating fire training for the staff team. EVIDENCE: The manager of the home has made an application to the Commission to be registered but this has not been approved as the home has been served with a Notice of Proposal to Cancel the registration. This has been adopted by the Commission and A Notice to Cancel the Registration was served. Service users, the staff on duty and a care manager were complimentary about the skills and commitment of the new manager describing her as having an The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 23 “open door, accessible style” being “approachable and friendly” and “committed to both the clients and staff in the home”. Service users and staff told us that the manager runs the home in the best interests of service users and people said they are involved in the running of the home. In a returned staff survey we were told, “ the new manager is always available for both formal supervision and informal support, she also sits in on handovers and on reviews for care plans”. A quality assurance process is in place and the Registered Provider told us that Progress Project questionnaires had been sent or given to all care coordinators, some family members and members of external agencies. The manager told us that outcomes would be used to inform the future improvements to the service being provided. Regulation 26, Provider’s visits are carried out by a nominated person and we saw that the Responsible Individual signs the completed reports. We saw incident and accident forms and although these are being completed, Regulation 37 reports concerning incidents that have an adverse effect on the welfare of service users are not being sent to the Commission as required. Records for the running of the home including fire records showed us that although regular fire equipment tests are undertaken, six monthly training for day staff and three monthly training for night staff were out of date. There was a current gas certificate in place and electrical appliance test had been carried out in February 08. Although at this visit we saw that there have been a number of improvements made to the service being offered in the home, there are only seven service users in residence at the present time. We discussed with the manager and the responsible individual, Mr Schiavone the need for further improvements to care plans, staff training, the environment and reporting Regulation 37 events. We discussed the need for the home to evidence that improvements to care standards could be maintained and how evidence of good care practice could be demonstrated over time, when other people might be living in the home. The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 24 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 N/A 2 N/A 3 N/A 4 N/A 5 N/A INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 N/A 23 N/A ENVIRONMENT Standard No Score 24 N/A 25 N/A 26 N/A 27 N/A 28 N/A 29 N/A 30 N/A STAFFING Standard No Score 31 N/A 32 N/A 33 N/A 34 N/A 35 N/A 36 N/A CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score N/A N/A N/A N/A N/A LIFESTYLES Standard No Score 11 N/A 12 N/A 13 N/A 14 N/A 15 N/A 16 N/A 17 N/A PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A The Progress Project DS0000064669.V371891.R01.S.doc Version 5.2 Page 25 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 15- (1) Requirement Care plans and risk assessments must be further developed to include agreed plans to guide the staff team in dealing with difficult and challenging behaviour To ensure that the staff team have the skills needed to support people, mandatory training needs to be updated for some people and challenging behaviour training provided for all members of the staff team To ensure the safety of service users, improvements are needed to the physical environment and decoration of the home and agreements must be in place with service users to ensure that their rooms are kept at a safe level of cleanliness. Regulation 37 reports detailing any event that has an adverse effect on a service user must be sent to the Commission as required. To ensure the safety of both service users and the staff team, the Registered Provider must consult with the Fire and Rescue DS0000064669.V371891.R01.S.doc Timescale for action 01/11/08 2. YA35 15-(2) 01/11/08 3. YA24 23-(2) (b) 01/11/08 4. YA41 37-(1) 01/11/08 5 YA42 18-(1) (c) 01/11/08 The Progress Project Version 5.2 Page 26 Service regarding staff training needs in fire safety matters. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 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