Care Home: 32 South Street

What the care home does well People living at 32 South Street have information about the service provided and their individual needs and aspirations are assessed on a regular and ongoing basis. People are able to make decisions about their lives and their assessed and changing needs and personal goals are reflected in their personal plans. People are encouraged and supported to be as independent as possible. A good variety of activities are regularly available, although people`s wishes are respected if they prefer to `do their own thing`. Staff have a good understanding of people`s rights and the importance of individuals making their own decisions with regard to daily living.The people living at 32 South Street receive personal support in the way they prefer, their physical and emotional health needs are met and they are protected by the home`s medication policies and procedures. 32 South Street has a clear complaints procedure, both formal and informal, which helps ensure that people feel their views are listened to and acted upon. Staff are well trained in areas such as mental health, adult protection and medication, to help ensure people are protected from abuse, neglect and self-harm as much as is possible. 32 South Street provides a homely, comfortable and safe environment for people to live in, which is clean and hygienic. 32 South Street has robust recruitment procedures, staff are well trained with regular updates, and they receive regular 1:1 supervision. The manager, who has been in post since April 2008, has completed the Registered Manager`s Award (RMA) and is currently in the process of completing the NVQ 4 in Care. What has improved since the last inspection? The bathrooms and toilets are checked regularly to ensure adequate toilet paper and hand washing facilities are always available. Regular `house` meetings are held, and records maintained, with the people living at 32 South Street and a more formal process has been established for obtaining feedback and views from service users, families and other professionals who have involvement with the service. The smoking lounge has new flooring and is checked regularly to ensure the safe disposal of the ashtray contents and ensure that there is no fire hazard. Risks have been identified with regard to people smoking within the home and appropriate action plans have been put in place. One of the communal `through` rooms was seen to have been converted into a `Theme` room, which has further helped to enhance the homely atmosphere at 32 South Street. The staffing levels and morale appear to have stabilised considerably since the last inspection. All the care plans have been reviewed and a number of them have recently been updated in a new format. What the care home could do better: Regular auditing must take place in order to effectively monitor people`s weights and a record of any action or intervention required must be maintained. Suitable telephone facilities must be available for use by the people living or staying at 32 South Street, with arrangements in place for use of these facilities in private. CARE HOME ADULTS 18-65 32 South Street Sheringham Norfolk NR26 8LL Lead Inspector Debra Allen Key Unannounced Inspection 6th February 2009 10:00 32 South Street DS0000027522.V374259.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 32 South Street DS0000027522.V374259.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. 32 South Street DS0000027522.V374259.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 32 South Street Address Sheringham Norfolk NR26 8LL 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) 01263 824040 01263 824040 info@prime-life.co.uk info@prime-life.co.ukwww.prime-life.co.uk Prime Life Ltd Ms Sara Doherty Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (19) of places 32 South Street DS0000027522.V374259.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person 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 to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 19 07/08/2007 Date of last inspection: Brief Description of the Service: 32 South Street accommodates 19 people with a mental disorder. The accommodation provides 19 single rooms, some with en-suite facilities on three floors. The top floor consists of a three bedroom flat with its own sitting room and bathroom and a bed sitting room with bathroom. This accommodation is used by those people who are more independent. Other people live together, sharing the communal accommodation. There is a small separate kitchen for people to make drinks, a variety of lounges, including a smoking lounge, and a theme room. There is also a very attractive garden. The Home is registered to accommodate those who are under 65 years of age and new admissions will meet this criteria. Because of the previous registration there are some people who are older than 65 and the Home is required to monitor their needs carefully to ensure they are catered for. The Home is in a quiet street in a residential area near to the town centre of Sheringham, within reach of the beach and the towns facilities. The fees are currently £325 per week, which is the basic rate and does not include any additional one-to-one staff support. 32 South Street DS0000027522.V374259.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 stars. This means the people who use this service experience good quality outcomes. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. The fieldwork of this inspection was carried out over a period of five hours, during which time discussions were held with the registered manager, records and files were checked, a tour of the premises was carried out and a number of people living at the home were met and spoken with. An Annual Quality Assurance Assesment (AQAA) was also jointly completed by the responsible individual and manager and submitted it to The Commission prior to this inspection. Two requirements have ben made as a result of this inspection. What the service does well: People living at 32 South Street have information about the service provided and their individual needs and aspirations are assessed on a regular and ongoing basis. People are able to make decisions about their lives and their assessed and changing needs and personal goals are reflected in their personal plans. People are encouraged and supported to be as independent as possible. A good variety of activities are regularly available, although people’s wishes are respected if they prefer to ‘do their own thing’. Staff have a good understanding of people’s rights and the importance of individuals making their own decisions with regard to daily living. 32 South Street DS0000027522.V374259.R01.S.doc Version 5.2 Page 6 The people living at 32 South Street receive personal support in the way they prefer, their physical and emotional health needs are met and they are protected by the homes medication policies and procedures. 32 South Street has a clear complaints procedure, both formal and informal, which helps ensure that people feel their views are listened to and acted upon. Staff are well trained in areas such as mental health, adult protection and medication, to help ensure people are protected from abuse, neglect and self-harm as much as is possible. 32 South Street provides a homely, comfortable and safe environment for people to live in, which is clean and hygienic. 32 South Street has robust recruitment procedures, staff are well trained with regular updates, and they receive regular 1:1 supervision. The manager, who has been in post since April 2008, has completed the Registered Manager’s Award (RMA) and is currently in the process of completing the NVQ 4 in Care. What has improved since the last inspection? The bathrooms and toilets are checked regularly to ensure adequate toilet paper and hand washing facilities are always available. Regular ‘house’ meetings are held, and records maintained, with the people living at 32 South Street and a more formal process has been established for obtaining feedback and views from service users, families and other professionals who have involvement with the service. The smoking lounge has new flooring and is checked regularly to ensure the safe disposal of the ashtray contents and ensure that there is no fire hazard. Risks have been identified with regard to people smoking within the home and appropriate action plans have been put in place. One of the communal ‘through’ rooms was seen to have been converted into a ‘Theme’ room, which has further helped to enhance the homely atmosphere at 32 South Street. The staffing levels and morale appear to have stabilised considerably since the last inspection. All the care plans have been reviewed and a number of them have recently been updated in a new format. 32 South Street DS0000027522.V374259.R01.S.doc Version 5.2 Page 7 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. 32 South Street DS0000027522.V374259.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 32 South Street DS0000027522.V374259.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, 2 & 4 Quality in this outcome area is good. People living at 32 South Street have information about the service provided and their individual needs and aspirations are assessed on a regular and ongoing basis, which helps ensure the service continues to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were looked at during this inspection and each of these were seen to contain detailed information with regard to the initial assessments that had been carried out prior to people moving in to 32 South Street. One of the people spoken to on the day confirmed that they had visited 32 South Street before moving in and had chosen to come and stay there. Meanwhile, a very informative and detailed ‘welcome’ pack was also seen to be available for people staying at 32 South Street, which included details of the menus, regular activities, a town centre map of Sheringham, local attractions and sightseeing information and feedback questionnaires. 32 South Street DS0000027522.V374259.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 & 10 Quality in this outcome area is Good. Each person living at 32 South Street continues to be able to make decisions about their lives and their assessed and changing needs and personal goals are reflected in their personal plans, which ensures the service continues to meet people’s individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were looked at in detail during this inspection and each one was seen to contain comprehensive information, which confirmed full needs assessments had been carried out prior to people moving into 32 South Street. These care plans were also seen to have been reviewed and updated, as necessary, on a regular basis. Improvements to people’s care plans and risk assessments have continued to be maintained since the last inspection and the manager is also in the process of updating all plans to a new format, which will help make recording and 32 South Street DS0000027522.V374259.R01.S.doc Version 5.2 Page 11 reviewing even more efficient. New formats were looked at for two people and these were seen to contain very clear and detailed information, including concise and regular reviews and evaluations. In general the care plans were seen to contain the following information: Admission details, including a procedure for missing persons, brief life history/personal profile, details of ‘significant others’ and arrangements concerning death. Care plans and risk assessments, which included mental health wellbeing, personal care/hygiene, records of weight and monthly evaluations. Record of health appointments. Clinical Psychology Assessments and reviews. Letters and correspondence. Daily/progress notes In respect of people making decisions about their lives, this was particularly observed by copies of correspondence in one person’s file, which related to their thoughts and wishes with regard to moving back into the community. Also, observations were made of people coming and going as they pleased and freely choosing what they wanted to do. The ‘Client Meetings’ folder was seen during the inspection, which included the dates and locations of meetings, comments written by the residents and the minutes, which showed the attendees (residents and staff) and contained well written and clear notes and explanations where necessary. One issue that was raised recently was where one resident asked if the menus and meal choices could be reviewed, as they didn’t feel they were substantial enough. A later comment was noted where a resident said they liked the home made food recently. Some of the topics which were noted to have been discussed during these meetings included medication, meals, trips out, daily activities, problems, the kitchen, fire alarm/drill, smoking, bedrooms, incentive schemes and holidays. Evidence was seen to show that people living at 32 South Street are supported to take risks in the form of well compiled risk assessments and various policies and procedures. During the inspection, all personal records and information were seen to be stored securely in the office, which helped to confirm that confidentiality was maintained for the people living at 32 South Street. 32 South Street DS0000027522.V374259.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): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is Good. The people living at 32 South Street are able to take part in activities that suit them, be part of the local community, enjoy leisure activities as they wish and have positive relationships with their family and friends. Peoples rights and responsibilities are respected and recognised in their daily lives. People living at 32 South Street are offered a healthy diet and enjoy their food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions were held with a number of people living at 32 South Street during the inspection and some told how they regularly enjoy walking into town or to the seafront on their own, or meeting friends, at the local café for example. One person was also observed going out with a ‘befriender’. Discussions also confirmed that people continue to be encouraged and supported to be as independent as possible and evidence was seen in the care 32 South Street DS0000027522.V374259.R01.S.doc Version 5.2 Page 13 plans looked at, of people making their own decisions and any limitations were agreed jointly, as part of the care planning process. The activities folder showed a good variety of activities being offered and available regularly, although it was evident that a number of people genuinely preferred to ‘do their own thing’. The folder contained information with regard to the date, activity held/offered, number of people attending and the number of people who declined. Some of the group and individual activities noted from the activities folder and some of the care plans included: scrabble & board games, cooking, art & craft, Sheringham market, walk to beach and coffee out, ladies pampering, film/DVD, bingo, visiting family, darts, meal out at restaurant, bistro or café, trips to Gressenhall and Blickling, ten pin bowling, trip to garden centre, Priory Maze, shopping and pub visits. Discussion with the manager and observations throughout the inspection confirmed that the staff continue to have a good understanding of people’s rights and the importance of individuals making their own decisions with regard to daily living. Discussions with some of the people living at 32 South Street confirmed that people mostly enjoy the meals, although one person did comment that the vegetables weren’t always cooked properly. The menus showed a good selection of wholesome and nutritious meals being offered and alternative choices available in respect of main meals and snacks. Various observations were also made throughout the course of the inspection, which confirmed that people could genuinely choose what, when and where they wanted to have their meals and one person commented that they were going to cook themselves an omelette that evening. 32 South Street DS0000027522.V374259.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 & 20 Quality in this outcome area is Good. The people living at 32 South Street receive personal support in the way they prefer, their physical and emotional health needs are met and they are protected by the homes medication policies and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with some of the people living at 32 South Street, and information seen in the care plans, helped to confirm that peoples individual wishes are acknowledged in respect of the way they are supported, which appeared to be mostly by listening to, encouraging or prompting people with daily or personal healthcare tasks. Some people were noted to require slightly more support than others in areas such as washing/bathing or dressing/undressing. People are supported to administer their own medication where possible and appropriate risk assessments are in place for this. Meanwhile, the home was seen to have good and safe practices with regard to the handling, administration and recording of medication and no errors or omissions were noted in the records during this inspection. 32 South Street DS0000027522.V374259.R01.S.doc Version 5.2 Page 15 Other records looked at confirmed that people are supported to have regular and ongoing involvement with various care professionals such as doctor, nurse, psychiatrist, dentist, optician, dietician and chiropodist. It was noted however that, although people’s weights are recorded in their care plans, there was no evidence of auditing or action being taken where there were notable increases or weight losses – i.e. records for one person showed that their weight had fallen from 13.2 stone in October 2007 to 10.4 stone in October 2008, while another person’s records indicated that their weight had increased from 17.7 stone in October 2007 to 19 stone in January 2009. A requirement has therefore been made to this effect. 32 South Street DS0000027522.V374259.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 & 23 Quality in this outcome area is Good. 32 South Street has a clear complaints procedure, both formal and informal, which helps ensure that people feel their views are listened to and acted upon. Staff are well trained in areas such as mental health, adult protection and medication, to help ensure people are protected from abuse, neglect and self-harm as much as is possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From the information provided in the AQAA, 32 South Street has received four complaints in the last twelve months, all of which were resolved appropriately and in accordance with the homes complaints procedure. Other information provided in the AQAA confirmed that, for 2008, 32 South Street have reviewed all their literature to ensure that the contact details to raise concerns and complaints are accurate. In-house and externally accredited training opportunities continue to be provided for staff in the important issue of the Protection of Vulnerable Adults (POVA). It was also stated that the Human Resources (HR) department provides periodic audits of Prime Life’s care centres, to confirm that all staff are appropriately referenced, and the HR Department are working together with the Commission for Social Care Inspection to try and improve the performance of the return of the Criminal Records Bureau checks. 32 South Street DS0000027522.V374259.R01.S.doc Version 5.2 Page 17 Meanwhile, the complaints book was looked at during the course of the inspection and included internal comments made by some of the people living at 32 South Street, which had been actioned accordingly. Training records were also looked at, which confirmed that staff are well trained, particularly in areas such as mental health, adult protection and medication. 32 South Street also has robust recruitment procedures, which are covered in more detail in the Staffing section of this report. 32 South Street DS0000027522.V374259.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, 26, 27, 28 & 30 Quality in this outcome area is Good. 32 South Street provides a homely, comfortable and safe environment for people to live in, which is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises showed further improvements to some rooms, in respect of new carpeting and redecoration and all of the areas seen during the inspection clean, hygienic and free from any offensive odours. The toilets and bathrooms were also looked at and these were seen to be clean, with adequate facilities available in respect of toilet paper and handwashing, confirming that the previous requirement had been complied with. The smoking lounge was also seen and this was found to be clean and tidy, with new flooring and obvious attention to ensuring litter is disposed of and 32 South Street DS0000027522.V374259.R01.S.doc Version 5.2 Page 19 ashtrays are emptied regularly and safely. This also confirmed compliance of a previous requirement. One of the communal ‘through’ rooms was seen to have been converted into a ‘Theme’ room, which has further helped to enhance the homely atmosphere at 32 South Street and some of the people spoken to said they enjoyed making and contributing to the decorating of this area on a regular basis. Individual rooms that were seen, were observed to be clean and personalised and two of the people spoken to said that they were very happy with their rooms. Meanwhile, it was noted and commented on by some of the people living at 32 South Street, that the communal pay-phone has been out of order for some considerable time and that there were no immediate plans to have it repaired or replaced. A requirement has therefore been made to this effect. 32 South Street DS0000027522.V374259.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, 34, 35 & 36 Quality in this outcome area is Good. 32 South Street has robust recruitment procedures, staff are well trained, with regular updates, and they receive regular 1:1 supervision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three staff files were looked at during the inspection and each of these were seen to contain evidence of appropriate references, clear enhanced disclosure from the Criminal Records Bureau (CRB), application form, identification, contract, starter form and induction information. Each staff member also has a training folder and, of those seen, there was evidence of courses and training that had been undertaken such as moving & handling, fire safety, food hygiene, first aid, mental health, medication – handling and administration, early days learning, adult protection, COSHH, the common induction standards and managing challenging behaviour (NAPPI). Good evidence was seen by way of the personnel files and the home’s training records, which confirmed that staff training is regular, with ongoing updates. 32 South Street DS0000027522.V374259.R01.S.doc Version 5.2 Page 21 All the records seen also contained evidence of staff receiving regular support and supervision from their line manager. Meanwhile, the staffing levels and morale appear to have stabilised considerably since the last inspection and it was evident that both the previous acting manager and the current manager have worked hard, since the last inspection, to restore and maintain the balance within the home. 32 South Street DS0000027522.V374259.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, 39 & 42 Quality in this outcome area is Good. 32 South Street is a well run home and the people living there benefit from good quality leadership and day-to-day management. The people living at 32 South Street also know their health, safety and welfare is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The permanent, manager, who has been in post since April 2008, has completed the Registered Manager’s Award (RMA) and is currently in the process of completing the NVQ 4 in Care. 32 South Street DS0000027522.V374259.R01.S.doc Version 5.2 Page 23 It was evident throughout the inspection that the current manager has worked hard to restore the balance at the home, not only for the staff but also with regard to consistency of care for the people living at the home. It was noted that all the care plans have been reviewed and a number of them have recently been updated in a new format, which is making recording and retrieving information much more effective and consistent. As mentioned in a previous section, regular meetings are held with the residents and there is a good quality assurance process in place now, which invites feedback from both permanent and respite guests. Health and safety was noted to be well promoted and the records looked at were up to date, including the home’s general risk assessments, fire risk assessment and general policies and procedure. A fire safety assessment was seen to have been completed by Norfolk County Council’s Fire and Rescue Service in January 2009. Chemicals and cleaning materials were also seen to be stored appropriately. 32 South Street DS0000027522.V374259.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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 3 X 32 South Street DS0000027522.V374259.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 YA19 Regulation 13 Requirement Timescale for action 12/08/09 2. YA26 16 12/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 32 South Street DS0000027522.V374259.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. Extracts may not be used or reproduced without the express permission of CSCI 32 South Street DS0000027522.V374259.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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