Care Home: 3a Grosvenor Road

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What the care home does well 3a Grosvenor Road is an established, well-managed and well maintained service that continues to provide good quality care and support for the people who live there. The comfortable, relaxed and welcoming environment has evolved over several years and reflects the varied interests and personalities of the residents, the commitment within the staff team and the open and inclusive management style. Thorough policies and procedures are in place for the admission and ongoing care and support of service users. Effective communication and consultation systems enable residents to be directly involved in developing and reviewingtheir individual support plans as well as many decision-making processes within the home. Residents are enabled and supported to take part in a comprehensive range of educational and leisure activities, reflecting their individual interests and preferences, both within the home and in the wider local community. What has improved since the last inspection? As recommended following the previous inspection a training matrix has been developed and implemented, to provide details of what training has been undertaken by which staff member and when. Since the last inspection a total refurbishment and upgrading of the first floor bathroom has taken place. The hallway, stairs and landing and two bedrooms have also been redecorated. In the kitchen a new dishwasher has been provided. What the care home could do better: Information regarding the service made available to prospective residents, including the Statement of Purpose, should be reviewed and amended to accurately reflect the current situation regarding the management structure within the home and updated contact details for the Association. The damaged and worn carpet in the lounge should now be replaced. CARE HOME ADULTS 18-65 3a Grosvenor Road Seaford East Sussex BN25 2BL Lead Inspector Nigel Thompson Unannounced Inspection 14th August 2008 09:30 3a Grosvenor Road DS0000021006.V368923.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 3a Grosvenor Road DS0000021006.V368923.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. 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3a Grosvenor Road Address Seaford East Sussex BN25 2BL 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) 01323 890435 grosvenormanagers@southdownhousing.org Southdown Housing Association Ltd Miss Trudy Bryan Care Home 3 Category(ies) of Learning disability (0) registration, with number of places 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 3. Date of last inspection 6th March 2007 Brief Description of the Service: 3a Grosvenor Road is a Southdown Housing Association service registered to provide care to three younger adults who have a learning disability. The home is an attractive, detached property located in a residential area close to the Seaford town centre amenities, including main line railway station and bus routes. On the ground floor, there are three single bedrooms, a large bathroom, kitchen, lounge and dining room. On the first floor is a self-contained flat with a bedroom, lounge and bathroom. There is a large, well-maintained garden to the rear of the property. Information about the service, including the recently updated Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The current range of fees at 3A Grosvenor Road, as of 6 March 2007, is £1295.49 - £2,000 per week. Additional charges are made for hairdressing, magazines, toiletries, certain day services and holidays. 3a Grosvenor Road DS0000021006.V368923.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. This key unannounced inspection took place over four hours in August 2008. It found that all of the key National Minimum Standards were assessed and found to have been met or partially met and the overall quality of care provided was good. Residents spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to monitor care practices at the home and the focus was on the quality of life and outcomes for people who live at the home. On the day of the inspection there were three residents living at the home. The inspection involved a tour of the premises, observation of working practices, examination of the home’s records and discussion with two residents, the registered manager and two members of staff. Information received in the Annual Quality Assurance Assessment (AQAA) and responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. What the service does well: 3a Grosvenor Road is an established, well-managed and well maintained service that continues to provide good quality care and support for the people who live there. The comfortable, relaxed and welcoming environment has evolved over several years and reflects the varied interests and personalities of the residents, the commitment within the staff team and the open and inclusive management style. Thorough policies and procedures are in place for the admission and ongoing care and support of service users. Effective communication and consultation systems enable residents to be directly involved in developing and reviewing 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 6 their individual support plans as well as many decision-making processes within the home. Residents are enabled and supported to take part in a comprehensive range of educational and leisure activities, reflecting their individual interests and preferences, both within the home and in the wider local community. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 3a Grosvenor Road DS0000021006.V368923.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 3a Grosvenor Road DS0000021006.V368923.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, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The thorough admission policy and procedure ensures that residents are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective residents know that the home is able to meet their individual care and support needs. EVIDENCE: There have been no admissions to 3a Grosvenor Road since the previous inspection. Two of the residents have lived at the home for eighteen years and the third for six years. All three residents are evidently very happy and settled. The manager confirmed that should a vacancy exist any prospective resident would only be accepted on completion of a full assessment process. Referrals are made by social services through a care management process. Assessments would be carried out by the area manager and the service manager, with the resident, their family, advocates and current care providers. 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 9 As part of the service’s thorough admission procedure, a detailed preadmission assessment form has been developed and includes information relating to the individual’s personal, medical, social and psychological care and support needs. Prospective residents and their relatives are encouraged to visit the home and have the opportunity to look around and meet with members of staff and existing residents. The manager confirmed that any new resident would undergo a flexible trial period at the home, during which time their suitability and compatibility are assessed and it is established whether their identified care and support needs are able to be met. Information regarding the service is available to prospective and existing residents in various formats. The Statement of Purpose and Service User Guide have been thoughtfully and imaginatively produced to a high standard and are both comprehensive and informative. The Service Users’ Guide is presented in an easy to read and understand format, which incorporates the use of pictures and symbols. It gives an overview of the philosophy of care, purpose of the service, accommodation and outlines what support and care individuals can expect from the home. However it was noted that the Statement of Purpose was last reviewed in June 2006 and consequently contained inaccurate and outdated details relating to the management structure within the home and contact details for the organisation’s Head Office. 3a Grosvenor Road DS0000021006.V368923.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Comprehensive care plans enable staff to meet the assessed support needs of residents in a structured and consistent manner. Systems for consultation and participation are effective. Residents are treated with respect and encouraged and enabled to make decisions about their day-to-day living. EVIDENCE: High quality, ‘person centred’ care plans (Support Plans) have been thoughtfully developed for each resident and are clearly linked to the individual’s assessed needs. The plan, covering in detail ‘the person’ and ‘the support’ is formulated by the key-worker, manager and evidently with the direct involvement of the resident or family member, as appropriate. 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 11 Individual plans that were examined contained clear documentary evidence of regular reviews having taken place. In addition to details of who attended the ‘planning meeting’, the comprehensive minutes included a review of previous goals, ‘Aims and objectives of the plan’; ‘Day services / weekly timetable’; ‘Health and daily support’ and ‘Future Goals’. A summary of the discussion is also recorded and is completed and signed by the person chairing the meeting. The manager confirmed that each resident attends their own reviews and is actively supported to participate as much as they want to: ‘The residents use their picture diaries to look back on what they have done in the last six months. This enables them to have full control of their reviews.’ Staff spoken with during the inspection confirmed that, despite the variable and limited verbal communication of some residents, effective and regular interaction and consultation takes place constantly throughout the home. This was evident from direct observation of staff supporting residents in a professional, sensitive and respectful manner. All residents continue to be enabled to take responsible risks, where necessary, in order to promote their independence. Detailed risk assessments and guidance are in place for all activities of daily living, based on the needs of individuals. Examples include: self-medicating, going out in the car, managing finances, going out into the community unsupported and maintaining personal relationships with others. All risk assessments are evidently reviewed regularly and updated as necessary. In accordance with the person centred approach to care planning, it was noted that such assessments are recorded in the first person and provide evidence of regular and effective consultation with residents. Individuals continue to be encouraged to make decisions about many aspects of their life and are made aware of and sensitively supported to understand the reasons for specific action being taken. 3a Grosvenor Road DS0000021006.V368923.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. This judgement has been made using available evidence, including a visit to this service. Residents are enabled and supported to maintain contact with family and friends as they wish and effective links with the community enrich their social and educational opportunities. Residents benefit from appropriate educational and leisure activities and menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: The recreational and leisure interests of residents are identified and recorded in their individual care plan and they continue to be supported to access activities and facilities, reflecting their individual needs, preferences and abilities. 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 13 Individual support plans examined confirmed that residents are enabled to access a variety of recreational and leisure activities, including shopping and swimming. Community participation evidently remains a focus within the home and staff confirmed that, in accordance with their individual choice and preference, residents are encouraged and supported to attend day services, college, visit local shops, libraries, restaurants and other amenities. One resident is directly involved in the ‘courier run’ for internal mail for all Southdown services and then delivers mail to the office. Activities offered in the house include cooking, watching a DVD, having a weekly session with a music therapist, room clean to music, art and craft sessions, foot massage, baking and games sessions. A music therapist visits the home once a week to do a music session with two of the residents on an individual basis. These sessions are evidently adapted to their identified needs and preferences. All three residents are encouraged and enabled to make choices regarding what they prefer to do and how they spend their day, within the home or out in the community. They are supported by staff, on a 1:1 basis, with their structured day services programme and the manager confirmed that: ‘Each resident is very much in control of what they would like to do’. Resident are given the option to go on a holiday each year and this is discussed both in reviews and residents’ meetings. Staff confirmed that visiting to the home is largely unrestricted and relatives and friends are made welcome at any reasonable time. Residents are encouraged and supported, where appropriate, to maintain family links. However the manager confirmed that not everyone in the home enjoys regular contact. Menus are varied and balanced and are evidently based on residents’ identified likes and preferences. An alternative to the main meal is always available. All meals are prepared within the home by care staff who have attended a Food Hygiene course. Should they choose to, residents are enabled to participate in food preparation. It was noted that individuals have made the choice to eat their meals separately and are evidently offered discreet support as necessary. 3a Grosvenor Road DS0000021006.V368923.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. This judgement has been made using available evidence, including a visit to this service. Staff have developed close and positive relationships with residents and demonstrate an awareness and sound understanding of their individual care and support needs. Residents are protected by clear and comprehensive policies and procedures in place for the control and safe administration of medication. EVIDENCE: The manager emphasised the importance of staff developing close working relationships with individual residents, communicating effectively and being aware of changes in mood or behaviour. This was clearly evident during the inspection when residents were observed being supported in a sensitive, professional and respectful manner. 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 15 In accordance with their personal care plan, and as previously documented, residents are fully supported and enabled, as far as practicable, to exercise control over their lives and maintain maximum levels of independence and individuality. Documentary evidence was in place to demonstrate that the health and emotional care needs of service users continue to be met within the home. All residents are registered with local GPs and have access to other health care professionals, including district nurses, speech and language therapists and dentists, as required. All medical appointments with, or visits by, health care professionals are appropriately recorded. The manager confirmed that all personal care is always carried out in private areas, and in accordance with residents’ preferences. Up to date and detailed policies and procedures relating to the control, storage, administration and recording of medication are in place. Medicines are stored and recorded appropriately. All staff responsible for administering medication have received training, as part of their comprehensive induction programme, and are individually assessed and authorised to do so. The manager confirmed that, following risk assessments, no service user currently self-administers their own medication. 3a Grosvenor Road DS0000021006.V368923.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. This judgement has been made using available evidence, including a visit to this service. The home’s complaints procedure ensures that residents and staff feel able to express any concerns, confident that they will be listened to and acted upon. Residents are protected, through relevant staff training and robust policies and procedures relating to abuse and safeguarding vulnerable adults. EVIDENCE: A detailed complaints procedure is in place, which is outlined in the service user guide and statement of purpose. All complaints are recorded and investigated. There is a pictorial complaints leaflet available in the service. The manger confirmed that any complaints and concerns are listened to, and appropriate action is taken to resolve the issue. Complaints are responded to within 28 days, and a record of all complaints is kept with details of the action taken and outcome. It is also evident from direct observation and through discussions with staff that the close working relationships, effective communication and consultation and regular residents’ meetings provide adequate opportunities for any concerns to be raised and discussed, before they become complaints. 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 17 Residents and members of staff, spoken with during the inspection, confirmed that they would have no hesitation in speaking to the manager or making a complaint if necessary and each person was confident that they would be listened to. It was noted that no complaints have been received by the home since the previous inspection. The home ensures as far as is practicable that residents are safeguarded from all forms of abuse and policies and procedures relating to Adult Protection, including a policy on alerting, ‘Whistle Blowing’, are in place. Safeguarding Vulnerable Adults training is mandatory and recorded for individual staff. This involves ensuring all staff are aware of the various types of abuse, and how it may present itself. During the induction process, staff read the whistle blowing policy, and have knowledge of how to report suspected/known abuse. Crisis Intervention team training and refresher training is provided annually based around the individual needs of the resident’s service. Restraint techniques are not used within this service. The manager confirmed that all staff are trained in managing challenging and potentially aggressive behaviour of residents. They are trained to work proactively with crisis intervention, the model described by the Crisis Prevention Institute. (BILD accredited). Clear guidelines have been written up in all three residents’ support plans, detailing situations where they will need closer support. 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The service is accessible, safe and clean and is clearly suitable for its stated purpose. Residents benefit from pleasant accommodation that is comfortable, well maintained and furnished and decorated to a reasonable standard. EVIDENCE: During my ‘guided tour’ of the premises it was evident that the physical environment of the home remains largely unchanged since the previous inspection. The generally well maintained décor and adequate furniture and furnishings continue to provide a comfortable, safe and pleasant environment for residents. 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 19 The manager confirmed that individuality and independence continue to be promoted within the home, as far as is practicable. This was evident from the personalising of residents’ rooms, which clearly reflects individual tastes, preferences and interests. Adequate communal areas are provided to meet the individual and collective needs of the residents, including a pleasant dining room and a spacious lounge. All communal areas are decorated and furnished to a satisfactory standard. Furniture and lighting throughout the home is domestic in character. Since the previous inspection a total refurbishment and upgrading of the first floor bathroom has taken place. The hallway, stairs and landing and two bedrooms have also been redecorated. In the kitchen a new dishwasher has been provided. Following discussion with the manager, it is recommended that the torn and worn carpet in the lounge be replaced. Staff are responsible for cleaning the home and on the day of the inspection levels of cleanliness were found to be satisfactory throughout. There is an organisational policy and procedure for infection control. Service specific guidelines have also been written, and staff are made aware of these. These include how to deal with soiled laundry, how to clear spillages etc, and risk assessments are completed for this. A programme of routine maintenance, renewal and redecoration is in place. 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There is always sufficient trained and competent staff on duty to meet the assessed needs of the residents. Residents are protected by satisfactory staff recruitment policies, procedures and documentation. EVIDENCE: Through discussion with the manager and care staff, it is evident that sufficient staff are employed in the home to meet the current assessed support needs of residents and to ensure consistency and continuity of care. The manager confirmed that staffing levels are closely monitored and are directly linked to the residents’ identified levels of dependency. A duty rota has been developed and implemented to detail the staff on duty at any given time and their designation. 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 21 Appropriate core skills training is provided, including first aid, food hygiene and fire safety. This was confirmed through discussions with staff and evidenced by training records examined: ‘There is always plenty of opportunity for training here’. Formal and structured staff supervision is provided on a regular basis and is appropriately recorded. In accordance with organisational policy, it is evident that the home continues to operate thorough and robust recruitment procedures, to ensure the protection of residents. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. 3a Grosvenor Road DS0000021006.V368923.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, 41 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents benefit from a competent and experienced manager and are protected by satisfactory health and safety procedures. Their best interests are safeguarded by adequate and effective quality monitoring systems. EVIDENCE: The registered manager has been in her current position since June 2006. She holds the Registered Manager’s Award (RMA) as well as the NVQ level 4 in Management and Care. 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 23 She evidently continues to maintain a relaxed, open and inclusive atmosphere within the home. Members of staff and a resident, spoken with during the inspection confirmed how approachable and supportive the manager is. A comprehensive quality assurance file is in place, which has been produced by Southdown Housing Association. The modules contained within this file are based on meeting the outcomes of the National Minimum Standards (NMS) in addition to ensuring that regular health and safety checks including the maintenance of the home’s vehicle are undertaken. Additional quality monitoring systems are in place, including regular satisfaction surveys for both residents and their relatives. Since the previous inspection the satisfaction questionnaire has been extended to seek the views of advocates and other stakeholders. Positive comments received from residents’ relatives indicate a high level of satisfaction with the home, the staff and the services provided: ‘…… how very grateful I am for the care and attention that is given to …… by all at 3a’ The manager confirmed that the health, safety and welfare of residents and staff remain of paramount importance within the home and staff training is provided in many aspects of safe working practices, including moving and handling, fire safety, food hygiene and first aid. COSHH assessments and guidelines are in place. Temperature regulators are fitted to all hot water outlets, accessible to residents. All accidents, incidents and injuries are recorded and reported, as required. 3a Grosvenor Road DS0000021006.V368923.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 3 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 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 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 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 3 3 X 3 X 3 X 3 3 X 3a Grosvenor Road DS0000021006.V368923.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. Standard Regulation Requirement Timescale for action 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 It is recommended that the Statement of Purpose be reviewed and amended to include accurate information regarding the management structure and updated contact details for the Association. It is recommended that the carpet in the lounge be replaced. 2. YA24 3a Grosvenor Road DS0000021006.V368923.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 3a Grosvenor Road DS0000021006.V368923.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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