Inspection on 24/08/06 for Townley Road, 2-3

This inspection was carried out on 24th August 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Townley Road, 2-3 12/06/08

Townley Road, 2-3 04/01/06

Townley Road, 2-3 14/10/05

Townley Road, 2-3 24/03/05

Townley Road, 2-3 14/12/04

Townley Road, 2-3 11/03/04

Similar services:

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Ashwood House (Leyton)

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

CARE HOME ADULTS 18-65 Townley Road, 2-3 East Dulwich London SE22 8SW Lead Inspector Lisa Wilde Unannounced Inspection 24 August 2006 2:00 th Townley Road, 2-3 DS0000007000.V310003.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 Townley Road, 2-3 DS0000007000.V310003.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. Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Townley Road, 2-3 Address East Dulwich London SE22 8SW 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) 020 8299 1841 020 8299 0820 townley_road@hexagon.org.uk Hexagon Housing Association Ms Norma Smellie Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 10 patients adults with mental health disorders (on leave), to include one patient aged above 65 years In addition to the 10 (ten) residential service users, the home may provide day care facilities for up to two extra service users (aged 18-60 years) with mental health disorders, for the purposes of rehabilitation, given that at least two of the residential service users are off the premises during the day care period 4th January 2006 Date of last inspection Brief Description of the Service: Townley Road is a care home providing care, nursing and accommodation to ten service users with mental health needs. It aims to provide placements of two to three years to enable service users to move on to a range of other housing options. The home is owned and run by Hexagon Housing Association The home is located in East Dulwich, close to the train station, shops, banks, a post office and bus services. The home is a three storey residential building with bedrooms on the first and second floors. All bedrooms are single. There is a communal lounge, dining/games area and quiet room along with a large kitchen. There is a small kitchenette on the first floor. There is no passenger lift and the home is not wheelchair accessible. There is a garden to the rear. At the time of this inspection there were no vacancies at the home. Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in August 2006. The inspector met with service users, staff and the deputy manager. All service users who spoke to the inspector said they were very happy at the home and had no problems. They liked their rooms and said they had everything they needed. One service user said that staff helped them feel safe and well another said that staff were good and helpful. This is an excellent home. The inspector found again that the evidence was much the same as at the last inspection and a very high standard of nursing care and general support is being offered to the service users. The home continues to meet or exceed most of the National Minimum Standards, with only one requirement around medication made at this inspection. Staff show a real commitment to improving the service for the benefit of the people living there. Service users, staff and managers are to be commended for the work they are doing together to create a supportive and effective rehabilitation programme at this home that allows service users to become more confident, develop coping and life skills and make positive moves to less supported accommodation. What the service does well: From the standards assessed at this inspection the home showed that: • prospective service user’s needs are fully assessed before they are offered a place at the home. • prospective service users visit the service for a series of trial stays to meet service users and staff and get to know the home before they decide finally to move there. • service users know their needs and goals are described in their individual plans and action is identified to meet those needs and achieve those goals. • service users are supported to make their own decisions. • staff consult with service users about day-to-day life at the home and their views are listened to and changes made where possible. • risk is seen as an essential part of life at this home but identified risks are managed and minimised. • service users are offered a variety of activities and development opportunities within the home. • service users are supported to see their family and friends as they choose and to find ways to meet people and develop intimate relationships if they choose to. • the whole ethos of the home is based on service users taking responsibility for their lives. • the home offers a structured programme of rehabilitation and skills development around cooking and menu planning. Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 6 • • • • • • • • • • service users’ personal and health care needs are fully met. medication is handled and stored safely and service users can work towards taking their own medication. service users know how to complain and are listened to when they do have concerns. service users are protected from abuse. the home is homely, comfortable and clean throughout and service users rooms are large enough and suit their own individual taste. service users are supported by a competent, trained and qualified staff team. the organisations’ recruitment policy and procedure makes sure that good staff are employed. the Registered Manager is fit to be in charge and the home is well run. service users’ views are listened to and form the basis of how the home develops and improves. the health, safety and welfare of service users are being promoted and protected by the home’s procedures and practice throughout the building. 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. Townley Road, 2-3 DS0000007000.V310003.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 Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes a full assessment of a prospective service user’s need following their initial referral. The team decides together whether it is able to meet those needs so that service user knows from the outset that the home has established if it can offer them an effective service. Prospective service users visit the service for a series of trial stays to meet service users and staff and get to know the home before they decide finally to move there. EVIDENCE: There is new legislation in place now that will come into force on 01/09/06 and 01/10/06 which will require services to state exactly what fees each service user is paying and how it breaks down into different areas, in the service user guide. (See Recommendation 1) The deputy manager described the assessment process, which includes a written referral being made by South London and Maudsley Team and then the manager going out to visit the service user with another member of staff to undertake the home’s assessment. These assessments were seen on file for a random sample of service users and covered all the required areas. The team Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 9 then decides if they can meet the service user’s needs and then the service user is invited for a series of trial stays. Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users know their needs and goals are described in their individual plans and action is identified to meet those needs and achieve those goals. Service users are supported to make their own decisions by staff giving them information about the consequences of any action they may take. Staff work with families to make sure that they understand the work of the home and to try to make sure that everyone involved is working towards the same goals. Staff consult with service users about day-to-day life at the home and their views are listened to and changes made where possible. Risk is seen as an essential part of life at this home but identified risks are managed and minimised so that service users are given information to make choices about what are reasonable risks to take. EVIDENCE: Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 11 The inspector examined random samples of files and these showed that care plans are thorough, include evidence of the service users participation and are reviewed regularly, the care plans appeared to be language that could be understood by service users and they later confirmed that they knew what their care plans were about. The wording of the plans shows that emphasis is being placed on the positive skills and achievements of service users in order or them to enhance these skills. Staff, managers and service users talked through a series of examples where they described situations where they are supported to make their own decisions about their lives. Families are consulted and given information about the work of the home in order to assist with everyone working towards the same aims and objectives. Service users are consulted through their key work sessions and residents’ meetings. There is a Tenant Participation Group within the organisation that is sometimes attended by service users from this home. There are annual questionnaires, which are completed and the results audited. Action taken as a result of the service users’ questionnaires is recorded and fedback to the service users. Risk is assessed thoroughly as part of the initial assessment and then on an ongoing basis throughout someone’s stay at the home. The deputy manager discussed some examples of how service users have been supported to take reasonable risks with their public transport, accessing the community and going on holiday abroad alone. Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are offered a variety of activities and development opportunities within the home. They are assisted to identify activities and programmes within the local community and then are supported to access those opportunities as required. Service users are supported to see their family and friends as they choose. Service users are supported to find ways to meet people and develop intimate relationships if they choose to. The whole ethos of the home is based on service users taking responsibility for their lives in the home and their individual rights are recognised while bearing in mind that their individual behaviour may have an impact on the other service users. The home offers a structured programme of rehabilitation and skills development around cooking and menu planning. Service users are supported by the rehabilitation cook and other staff, to learn or relearn how to manage a Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 13 budget, shop and cook a variety of meals that the group has chosen in their meetings. EVIDENCE: The deputy manager talked about the individual programmes of service users and the inspector examined files and spoke with service users. All the evidence showed that service users are being supported to identify appropriate activities and opportunities for personal development and are then enabled to access those opportunities as they choose. Service users are allowed to come and go as they please during the day and were seen to be part of the local community during the inspection. Service users undertake the chores of the house on a rota basis with staff assistance as part of a rehabilitation approach. The home offers several groups in house throughout the week which include medication compliance, hearing voices, music appreciation, health, women’s/men’s group, creative writing, exercise, grooming/normalisation, videos and current affairs. Most service users have family who are involved in their lives and staff support service users to continue to see family and friends as they choose. Limits are only placed on visitors to the home when those visitors affect other service users badly. Service users are supported to have partners and intimate relationships if they choose. Advocates are brought in when no family members are involved and the service user wants extra support. The whole ethos of the home is based on service users taking responsibility for their lives and for their actions in the home. There is a communal programme of cooking, shopping and cleaning that service users are expected to take part in as part of living at the home. There is a rehabilitation cook at the home who decides the menus, shops and cooks with service users. Service users develop their skills in cooking and cleaning up and receive certificates as they progress through the programme. Service users who have finished the programme can cook for themselves if they choose or continue to cook and eat communally. Service users said that they like the food at the home and get to choose it themselves menus showed that a variety of food is on offer and different options such as vegetarian or Caribbean choices are catered for. The meal that was offered on the day of the inspection was healthy, attractive and nutritious. Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users confirmed that they are offered personal support from staff as they choose to have it. Personal care and health care needs are met by staff or by accessing other professional services within the community. Medication is handled and stored safely and regular checks take place to make sure that service users are protected by staff’s administration of medication. Service users can work towards taking their own medication once they have shown that they are able and their doctor and care team agree with the decision. EVIDENCE: Service users are offered varying levels of personal support, dependent on their needs and they confirmed that staff help them as they want to be helped. Nursing interventions are offered should someone’s mental health state require more than social or emotional support. Care plans outline how service users are to be supported to maintain their life at the home. Staff showed awareness of these care plans. Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 15 Files showed that health care needs are addressed on a regular basis and service users supported to meet those needs either by staff at the home or by accessing local facilities. A psychiatrist visits the home every two weeks to address any issues and service users are linked into the local GP. On the day of the inspection one service user expressed a desire to see the dentist and was supported to make an appointment on the same day. The medication stocks and records were checked and all were found to be in order apart from some medications not being recorded as to be taken “when required” on the charts. (See Requirement 1) Managers are completing full audits and writing medication reports twice a week until they are confident that the training has been effective and then will revert back to the basic level of checking and monitoring. The community pharmacist attends every month and checks the medication systems. Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know how to complain and are listened to when they do voice concerns. Service users are protected from abuse by all staff attending training that is repeated in-house on a regular basis and by policies and procedures being in place for staff to follow should they become aware of any potential abuse. EVIDENCE: A complaints record is maintained at the home to ensure service users are supported to understand the process, and timescales and actions are clear. Records of investigation into complaints are thoroughly recorded. Day-to-day complaints and issues are recorded in the residents’ meeting. Action taken in response to service users’ comments, concerns and complaints in residents’ meetings is recorded in the minutes along with any feedback that is given at following meetings. Service users said that staff listen to them. Al staff have undertaken training around adult abuse and the new staff have been booked on it for late January. The managers have attended investigation training and were aware that their responsibility in these issues is to report any potential abuse to the relevant authorities and not conduct an investigation themselves unless those authorities decide this to be the best way forward. There have been no vulnerable adult issues at the home over the past year. Townley Road, 2-3 DS0000007000.V310003.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 at least once during a 12 month period. 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. The home is homely, comfortable and clean throughout. The communal areas provide a number of different spaces, which allow service users to be together or choose to spend time alone outside of their rooms. Service users rooms are large enough and personalised to their own individual taste. The home is not suited for service users who cannot manage stairs. EVIDENCE: The home is a three storey residential building with bedrooms on the first and second floors. All bedrooms are single. There is a communal lounge, dining/games area and quiet room along with a large kitchen. There is a small kitchenette on the first floor. There is no passenger lift and the home is not wheelchair accessible. There is a garden to the rear. There are four toilets, two baths and one shower and these are decorated in a homely manner. Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 18 The inspector saw one room, which was individualised to the service users’ personal taste and which they said they were happy with. Other service users said they were all happy with their rooms and furniture in it. The home offers to supply service users with the furniture and fittings required by the standard and should service users decide that they do not want any of this furniture this is recorded on their file. Current service users do not need any physical adaptations. The manager has undertaken an assessment under the Disability Discrimination Act and they have determined that it is not feasible to make this building wheelchair accessible. The Registered Manager is accessing information and packs to assist those with sensory impairments should they receive a referral from someone with such needs. On the day of the inspection the home was clean and hygienic throughout. Townley Road, 2-3 DS0000007000.V310003.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported by a competent, trained and qualified staff team although the home does not have an overall training and development plan in place which means that it is not possible to fully confirm that staff are receiving the most effective training possible. There are sufficient nurses and NVQ qualified staff on duty to meet the needs of the service users. The organisations’ recruitment policy and procedure is robust and effective. The required checks are carried out prior to staff starting employment and service users are protected by the home’s practice in this area. EVIDENCE: The home is meeting the target of 50 of its care being provided by staff who hold the NVQ Level 2 in Care or equivalent. Staff were able to discuss service users’ needs in detail and highlight how they were meeting those needs. There are always at least four staff on duty for ten service users during the day. At least one of these four will be a qualified nurse. At night there is one nurse and one support worker on duty. Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 20 There is an induction and foundation programme in place for when staff start work which meets the Skills For Care (previously TOPSS) requirements. The homes recruitment policy and procedure is appropriate and effective. The inspector saw the personnel files and Criminal Records Bureau checks for the two new members of staff and all were in order except that equal opportunities monitoring forms were kept on staff files when they should be held separately and anonymously. (See Recommendation 2) There was a previous requirement that the Registered Individuals must ensure that a training and development plan for the home is devised which establishes what the training expectations are for each role at the home. All individual staff training assessments must fit into this overall plan. This had now been done. The training record shows that extensive training is offered, either in-house or externally around core areas of training such as manual handling and fire awareness but also in the more detailed aspects of mental health and related issues. Staff complete forms to assess the effectiveness of training and decide action that is to be taken following training. For example, groups have been set up around medication compliance and hearing voices, following staff receiving training. Service users sometimes attend training with staff. There was a previous recommendation that the Registered Manager should conduct a training needs assessment of the service as a whole to make sure that the impact of the training programme is assessed, focussing on the actual benefits to service users. The deputy manager did not believe this had yet been done although she talked about how the managers take note of difference in staff practice and understanding following training. This monitoring can be formalised into a more comprehensive annual audit focussing on benefits to service users. (See Recommendation 3) There was a previous recommendation that the Registered Manager should consider ways in which to involve service users in assessing which training staff need and how effective training has been. As above this is generally done by including service users in training but could be more formalised within and audit of training. (See Recommendation 4) Townley Road, 2-3 DS0000007000.V310003.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is fit to be in charge. She has the necessary skills, experience and training to identify and understand the needs of service users and be able to manage the home to ensure that staff can meet those needs. Service users are benefiting from a well run home because of this. The organisations’ quality assurance system and the homes’ consultation with service users means that service users’ views are gathered and form the basis of the home’s review and development. The health, safety and welfare of service users are being promoted and protected by the home’s procedures and practice throughout the building. EVIDENCE: The Registered Manager has been in post for around sixteen years. She is a qualified nurse and holds the NVQ Level 4 in Management along with the Townley Road, 2-3 DS0000007000.V310003.R01.S.doc Version 5.2 Page 22 Certificate and Diploma in Management. Throughout previous inspections she has evidenced her detailed awareness of the needs of the home and of service users. Managers and staff show ongoing commitment to meeting all requirements from the Commission’s inspections. The home draws up development plans based on the views of service users and staff. These were seen and action has been taken to address the issues identified. The home has achieved Investors in People accreditation and is about to start its own internal system of quality assurance with regard to the care provided. Staff and service user questionnaires have been completed as part of this audit by a team of external consultants. Financial systems are audited internally and the organisation’s finances are audited by accountants. There are systems in place to monitor and audit all areas of the home’s work. The deputy manager talked about they are currently looking at the area of service user involvement and thinking with staff, service users and the new User Involvement Manager in the organisation about how best to develop this work. The inspector saw all the health and safety checks and certificates and these were all as required. On the tour of the building there were no health and safety issues identified. Townley Road, 2-3 DS0000007000.V310003.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 X 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 4 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 4 X LIFESTYLES Standard No Score 11 4 12 4 13 3 14 3 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 X 4 X 3 X X 3 X Townley Road, 2-3 DS0000007000.V310003.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 (2) Requirement The Registered Manager must ensure that all medication to be taken “as required” is recorded as such on the medication administration charts. Timescale for action 31/08/06 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 YA1 Good Practice Recommendations The Registered Individuals should begin work on establishing exactly how each service users’ fees break down and put these in their service user guide. (This will become a legal requirement on 01/09/06 for current service users and 01/10/06 for new service users). The Registered Manager should ensure that equal opportunities monitoring information is held anonymously and separately to staff personnel files. The Registered Manager should conduct a training needs assessment of the service as a whole to make sure that the impact of the training programme is assessed, focussing on the actual benefits to service users. Previous recommendation. The Registered Manager should consider ways in which to DS0000007000.V310003.R01.S.doc Version 5.2 Page 25 2. 3. YA34 YA35 4. YA35 Townley Road, 2-3 involve service users in assessing which training staff need and how effective training has been. Previous recommendation. 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