Care Home: 16 Mansfield Road

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What the care home does well Information about the Service was available to prospective service users, and people placing them, in order to make an informed decision about whether the Service is right for them. Service users` individual plans of care were person centred, and were being reviewed regularly, so they could be sure that their current needs and preferences were being fully met. The Service provided activities and services that were age-appropriate and valued by service users and promoted their independence. The Service was providing service users with personal support in the way they preferred and required and was meeting their physical and emotional health needs. Procedures for handling complaints and abuse were in place to make sure that service users were being protected. Service users were living in a clean, homely and comfortable environment that met their needs. The Service was well managed so that service users were protected and their best interests were promoted by the systems in place. Very positive comments were made by the two care managers spoken to after the inspection. One said, in response to the question of what does the Service do well, "Everything...they go above and beyond...very approachable...always time to talk". The other care manager said, "They go out of their way to promote (my client`s) needs". What has improved since the last inspection? Person centred planning had been fully introduced to ensure that service users` needs and wishes were incorporated into everyday aspects of their life. The Acting Manager had applied to us to become the Registered Manager and, since this inspection, he has been approved. The premises had been fully redecorated. Three of five requirements and thirteen of the fifteen recommendations, made at the last inspection, had been met. CARE HOME ADULTS 18-65 16 Mansfield Road Heanor Derby Derbyshire DE75 7AJ Lead Inspector Tony Barker Unannounced Inspection 18th June 2008 09:30 16 Mansfield Road DS0000020050.V368026.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 16 Mansfield Road DS0000020050.V368026.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. 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 16 Mansfield Road Address Heanor Derby Derbyshire DE75 7AJ (01773) 711270 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) paulhenshaw@unitedresponse.org.uk www.unitedresponse.org.uk United Response Manager post vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category: Learning disability - code LD. The maximum number of service users who can be accommodated is 4. 2. Date of last inspection 9th July 2007 Brief Description of the Service: This service provides accommodation for four younger adults with severe learning disabilities and associated conditions including autism, sensory disability and challenging behaviour. Four single bedrooms are provided in a detached house situated on a bus route near to the town centre of Heanor. 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The time spent on this inspection was 8 hours and was a key unannounced inspection. Survey forms were posted to service users’ relatives, staff and external professionals before this inspection. Completed surveys were received from one staff member. The service users all had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed working with and being cared for by staff. Two care managers was spoken to on the telephone following this inspection. The Acting Manager and two Senior Support Workers with Additional Responsibilities (SSWARs) were spoken to and records were inspected. There was also a tour of the premises. One service user was case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The preinspection, Annual Quality Assurance Assessment (AQAA), questionnaire was not received until after this inspection but is referred to in this report. The fees for the Service are from £991 to £1096 per week and stated in service users’ Individual Charter. A copy of the last inspection report from the Commission for Social Care Inspection (CSCI) is available, to service users and visitors, in the office. What the service does well: What has improved since the last inspection? 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 6 Person centred planning had been fully introduced to ensure that service users’ needs and wishes were incorporated into everyday aspects of their life. The Acting Manager had applied to us to become the Registered Manager and, since this inspection, he has been approved. The premises had been fully redecorated. Three of five requirements and thirteen of the fifteen recommendations, made at the last inspection, had been met. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 16 Mansfield Road DS0000020050.V368026.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 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the Service was available to prospective service users, and people placing them, in order to make an informed decision about whether the Service is right for them. EVIDENCE: The Acting Manager made available well-designed copies of the Service’s Statement of Purpose, Service Users’ Guide and Individual Charter. These used a mixture of text and symbols to aid service users’ understanding of the service provided. The Service Users’ Guide did not include service users’ views of the Service and the Acting Manager said he would include feedback from relatives and from the person centred review meetings. Each service user but one had their own Individual Charter available to them in their bedroom. There had been no service users admitted since the previous inspection. The Acting Manager confirmed he was aware of the need to ensure that a full assessment of need is provided before admission, in order to guide staff in meeting the person’s needs. The two care managers who were spoken to on the telephone following this inspection confirmed that the Service’s assessment arrangements ensured that accurate information was gathered so that individuals receive the right service. 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ individual plans of care were person centred, and were being reviewed regularly, so they could be sure that their current needs and preferences were being fully met. EVIDENCE: The Service’s care planning documents had improved considerably since the previous inspection. The Service was operating to a ‘person centred’ model for individual care plans, periodic reviews of need and action to be taken and for risk assessments. Care plans were holistic and gave comprehensive guidance to those who support the person. They clearly identified goals to work to and were being reviewed every six months to ensure that current needs were being focussed on. Monthly summary sheets had also been introduced. All these documents indicated that regular monitoring of individuals’ needs and preferences was taking place. The AQAA indicated that staff had been provided with training in ‘Person Centred Thinking. The two care managers who were spoken to on the telephone following this inspection were both impressed with the degree to which service users’ individual needs were 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 10 focussed on. One said staff were, “very aware of (the service user’s) needs and what makes them tick”. The other commented that staff, “go out of their way to promote (the service user’s) needs”. One Senior Support Worker with Additional Responsibilities (SSWAR) gave examples of service users making their own decisions and choices, with staff assistance. For example, one service user is enabled to choose between two choices of places to walk to. There was also evidence, in a ‘learning log’, of the case tracked service user deciding to take evening medication downstairs. The Service was sensitive to the need to ensure that service users’ views and opinions were being clearly identified. One file contained a letter to the Housing Society that owns the property from a continence nurse, acting as the service user’s advocate. This was in support of the person’s request for an en suite facility, extending their bedroom. Risk assessments were comprehensive and recorded in a person centred way they included columns headed ‘Important to me’ and ‘Important for me’. One SSWAR confirmed that service users benefit from taking ‘responsible’ risks. She gave as an example, service users making use of public transport. 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Service provided activities and services that were age-appropriate and valued by service users and promoted their independence. EVIDENCE: Two of the service users were being provided with four days a week day service at a Derbyshire County Council establishment and were being supported by care workers from the Service on a ‘personal day’ once a week. The other two were receiving a five-day-a-week day service from the Service’s staff. One SSWAR spoken to gave examples of service users taking part in activities that were valued by them and fulfilling. The case tracked service user was described as showing pleasure in activities, such as mowing lawns, by smiles and a generally happy demeanour. The case tracked service user and one other spent time away from the premises, during this inspection, mowing the lawn at another United Response care home. On their return it was clear from their expressions that they had enjoyed themselves. The case tracked service user’s care plan included a person centred goal ”to seek a potential 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 12 college course to enable me to develop further in my life”. This goal was echoed by one care manager spoken to on the telephone following this inspection. The lounge area contained a good supply of games and there was much photographic evidence, within the Home, of service users enjoying activities and holidays with staff. There was evidence of continuing service user involvement in the local community. The Acting Manager recorded in the AQAA that service users “are more engaged within their home and community”. One SSWAR spoke, at the inspection, of service users regularly visiting a local café and pub, swimming and playing badminton at a leisure centre, walking in the local park, and shopping at a local supermarket where ‘check out’ staff know them well. There was good contact between service users and their relatives, the Acting Manager said, except for one service user. This person had a befriender who was visiting every three months and they were going out for meals together. One SSWAR spoken to confirmed the positive relationships that three service users have with their families and described the extent of these contacts and the value for service users. The Acting Manager described mutually positive relationships between three of the service users - with the fourth person being more self-contained. There were friendships with service users at a nearby care home too. Service users’ daily routines were displayed on their bedroom walls using words and understandable symbols. One SSWAR provided evidence of daily routines that promote service users’ independence. For instance, the case tracked service user takes a bath without staff needing to be there – a written risk assessment addresses this matter. Another service user needs staff to help prepare the bath but then asks staff to leave. Both these service users are very aware of their own privacy needs, the SSWAR said, and will regularly let staff know this. One care manager spoken to said the Service was “exceptional” when it came to respecting individuals’ privacy and dignity. Service users’ involvement in meal preparation and clearing away after meals were described by the SSWAR. She also described a person centred approach regarding flexibility of hours spent by one service user in their voluntary work at a local train station during their ‘personal day’. Food stocks were examined and found to be at a good level, including fresh fruit and vegetables. The Home’s four weekly rolling menus indicated that meals were balanced and nutritious. There was no record of food actually eaten by service users: menus showed “Service users’ choice” at lunch times and there was no record if an alternative to the recorded evening meal was eaten. Such a record would help in monitoring service users’ diet. One SSWAR said that all service users were involved in food shopping, preparation and clearing up after meals. Two service users were eating lunch during this inspection – there was a relaxed atmosphere. 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Service was providing service users with personal support in the way they preferred and required and was meeting their physical and emotional health needs. EVIDENCE: The Acting Manager said that the Housing Society that owns the property has agreed in principle to extend one service user’s bedroom in order to provide an en suite facility. A letter was seen to confirm support for this from a continence nurse. This facility would provide the person with increased privacy and independence. Two handrails were in place on the stairs to maximise service users’ independence and a shower seat met one service user’s needs. This service user had been provided with trousers with an elastic waist as the person was unable to use buttons. The staff member who responded to the postal survey stated that, “The Service promotes independence well, allowing the people we support to be able to do activities, household tasks, community access to the best of their abilities with minimal support if the individual is able to do so”. The Acting Manager stated in the AQAA that, “A support worker of black African origin” had been appointed to reflect the racial needs of one service user. That individual’s care manager was positive about the lengths to 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 14 which the Service go to ensure his client’s racial needs are met. There was a communications board in the kitchen that indicated, to service users, the staff on duty, day of the week and daily routine by means of ‘stick on’ symbols. This was up to date. The Acting Manager spoke of plans to provide each service user with their own communications board in their bedrooms. We observed positive interactions between staff and all service users on the day of the inspection. One SSWAR described a range of health professionals involved in service users’ lives and felt that all their health needs were well attended to. This was supported from an examination of records. There was evidence on files of a good range, and generally appropriate frequency, of health checks on service users. Health appointments were being recorded in ‘My Health File’ for all four service users. This was a small, compact and well-designed file, in place since early 2007, that was appropriately person centred. Further details arising from health appointments were being recorded on ‘Report/Feedback’ sheets. All these records were being fully used to ensure monitoring of health needs and action taken. Just two areas of concern were noted from the case tracked service user’s health records… • the person last saw an optician in August 2005 but the care plan referred to annual sight checks being needed, • the Medical Feedback report referred to the chiropodist recommending regular filing of the person’s toe nails but this was not explicitly reflected in their care plan. Service users were all described as being generally in good health, with conditions such as diabetes and epilepsy being well controlled. The Acting Manager described good practice through a person centred approach to one service user’s continence needs. Both care managers spoken to said that the Service’s Acting Manager and staff have the right skills and experience to support service users’ social and health care needs and these needs were properly monitored and attended to. The Service’s medication recording system was examined and was found to be satisfactory. The system of managing and recording ‘prn’ (as and when required) medicines, through individual written protocols, was also satisfactory. Medicines were being securely stored in cabinets in service users’ bedrooms providing, “a personalised medication system” as described in the AQAA. Sample staff signatures were recorded to ensure clarity on medicine records. Records confirmed that all staff had received training in the safe use of medicines within the past 3 years. Both care managers spoken to said that the Service was good at managing the administration of medicines to their respective clients. 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures for handling complaints and abuse were in place to make sure that service users were being protected. EVIDENCE: The Service’s complaints procedure was displayed in the entrance hall. It was satisfactory and included some symbols to help with service users’ understanding. The Service Users’ Guide contained a most comprehensive and commendable complaints procedure that included six examples of things that a service user may be unhappy about. For example, “Things you would like to do but you cannot do them” and “If there are people who are not kind to you”. It was stated in the AQAA that there had been no complaints received by the Service within the previous 12 months. An appropriate complaints record form was available for such use. The two care managers spoken to said the Service has always responded appropriately if they have raised a concern. One stated, “They will take my points on board”. The Service’s staff training matrix indicated that all staff but one had attended training, on keeping adults safe from abuse, within the previous four years. The Acting Manager had received this training in April 2008. One SSWAR was asked about the Service’s Safeguarding Adults procedures and ‘Whistle Blowing’ policy. She showed a good awareness. The Acting manager said staff had been reminded of the ‘Whistle Blowing’ policy at a staff meeting following the previous inspection. A copy of this policy was kept in the staff sleep in room. The Service’s written policy on responding to incidents of abuse was satisfactory and the Derbyshire Safeguarding Adults Protocol and Reporting 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 16 Forms were in place. There had been no physical restraint used on service users for several years, the Acting Manager explained. He said all staff had been provided with training in reducing incidents of physical intervention, and this was confirmed by records. 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were living in a clean, homely and comfortable environment that met their needs. EVIDENCE: The Home was attractively furnished and decorated and had a homely feel to it. Two bedrooms, used by service users with continence management needs, had vinyl flooring with a domestic carpet appearance. Bedrooms were very well personalised. Replacement windows were fitted and, as stated in the AQAA, the premises “has been recently been redecorated in line with the needs and wishes of the people we support”. The laundry room contained a washing machine and dryer. The washing machine had a sluicing programme that addressed the particular needs of two service users with continence needs. There were no unpleasant odours in the Home at the time of this inspection: it was clean and hygienic. One SSWAR was asked about infection control practices and she described good practices 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 18 and was aware of the Home’s infection control policy and associated risk assessments. 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Service’s level of staff training fell short of fully safeguarding the welfare of service users. EVIDENCE: Five out of the eight care staff had achieved a National Vocational Qualification (NVQ) to level 2 or above. This meets the National Minimum Standard to maintain a staff group with at least 50 qualified staff. One care manager spoken to described the Service as having “a settled staff team providing a consistent approach”. It was stated in the AQAA that only one part time staff member had left the employment of the Service within the previous 12 months. Other aspects of this standard were not assessed at this inspection. One staff file was examined – that of a support worker who started in June 2006. There had been no appointments since the previous inspection. All matters relating to the appointment of this person were satisfactory and met the requirements of the Regulations – indicating that adequate checks were being made about support workers’ suitability for caring for vulnerable adults. 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 20 Records indicated that newly appointed staff had been put forward for the Skills for Care Common Induction Standards so ensuring they had relevant job competencies. Records also confirmed that all staff had been provided with mandatory training except that no staff, including night staff, had been provided with Fire Safety training since January 2006. This was the position at the previous inspection. Although this is most concerning the Provider has given us his assurance that “Arrangements are now being made for all staff to receive fire safety training from other United Response managers who have been trained to present this material to support teams” and “The manager for 16 Mansfield Road will himself be trained to present fire safety training by the end of September”. The SSWAR spoken to confirmed she had been provided with First Aid and Basic Food Hygiene training within the past 12 months. The SSWAR spoken to also stated she had been provided with two one-to-one supervision sessions with the Acting Manager within the past two months. The Acting Manager said he was providing four supervision sessions a year to staff – an improvement on the previous year. 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Service was well managed so that service users were protected and their best interests were promoted by the systems in place. EVIDENCE: The Acting Manager of the Home had 17 years experience of working with people with learning disabilities and had an NVQ in Care and Management at level 4. He had made application to us to become the Registered Manager and, since this inspection, he has been approved. Records of the monthly, unannounced audit visits to the Home, undertaken on behalf of the Registered Provider, were all in place and up to date. There was no current Service Plan in place but there was written evidence of one being discussed at a staff meeting which, the Acting Manager stated, would feed through to a 2008/09 Service Plan by the end of July 2008. These quality 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 22 assurance measures indicated that due attention was being given to systematic Service reviews. Additionally, the Acting Manager said that relatives had completed satisfaction questionnaires although the Service had sent no satisfaction questionnaires to care managers or other external professionals. However, two care managers who we telephoned following this inspection were both very positive about the quality of care provided to their respective client. Cleaning materials were being safely stored in locked cupboards. Good food hygiene practices were being followed, including safe food storage and the monitoring of refrigerator and freezer temperatures. Monthly environmental hazard checks were being made and records of monthly fire drills and weekly fire alarm tests were also in place. The fire drills included six-monthly evening evacuations of everyone present in the Home. The AQAA indicated that electrical and gas equipment were being checked at appropriate intervals. 16 Mansfield Road DS0000020050.V368026.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 3 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 24 Yes 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 YA35 Regulation 23(4)(d) Requirement (Previous timescale was 01/10/07) Timescale for action 01/11/08 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. 2. 3. 4. 5. Refer to Standard YA17 YA19 YA23 YA36 YA39 Good Practice Recommendations A record should be kept of food actually eaten by service users, to help in monitoring their diet. The two aspects of health care provision to the case tracked service user, noted in this report, should be attended to. Further refresher training on keeping adults safe from abuse should be provided to those staff needing it. All staff should be supervised at intervals of two months to ensure that they are following good and safe practices in the Service. A Service Plan for 2008/09 should be developed. DS0000020050.V368026.R01.S.doc Version 5.2 Page 25 16 Mansfield Road 6. YA39 Satisfaction questionnaires should be sent to service users’ relatives and care managers. 16 Mansfield Road DS0000020050.V368026.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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