Care Home: 46 Grenville Road

Similar services:

• 2 Perhaver Park
• The Vicarage
• St George`s
• 5 Seafield Road
• Radfords
• Honeybourne House
• 32 Beaumont Way

What the care home does well The house is comfortable and warm. There is plenty of good food. People have enough things to do to be happy. There are always enough staff to help and people get all the help they need. Each person can have their room just as they want it. The staff know how to help people and the staff do their best. The staff are safe to be with. If a person has a problem it is easy to get help. If you want to live there the staff will make sure you can find out all about what it is like. What has improved since the last inspection? The staff are learning more ways to help people. What the care home could do better: It should always be written down whenever a person isn`t allowed to do something because they wouldn`t be safe. Some of the assessments of risks in the building should be done better. CARE HOME ADULTS 18-65 46 Grenville Road St Judes Plymouth Devon PL4 9PY Lead Inspector Brendan Hannon Unannounced Inspection 29th November 2007 9:45 46 Grenville Road DS0000049889.V347915.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 46 Grenville Road DS0000049889.V347915.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. 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 46 Grenville Road Address St Judes Plymouth Devon PL4 9PY 01752 310531 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) info@michaelbattfoundation.org Michael Batt Foundation (Valued Life Projects) Mrs Paula Bryant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Learning disabled adults some of whom may have a mental disorder Age 18-65 years One named service user under the category of physical disability. Date of last inspection 13th February 2007 Brief Description of the Service: 46 Grenville Road is a care home providing personal care and accommodation for three people, aged 18 - 65, with learning disabilities, who may also have associated challenging behaviour and mental health issues. It is owned by the Michael Batt Foundation (Valued Life Projects) which is a not for profit organisation providing services for people with a range of needs who require support and care to live in the community. The home was purchased by the present owners in October 2003 and is a midterraced property located in the residential area of St Judes in Plymouth. It is close to Plymouth City Centre and all local amenities. All the homes bedrooms are single and are on the 1st floor. None of the bedrooms have en suite facilities. There is a bathroom and a shower room on the 1st floor, both of which contain toilets. There is a lounge room, an activities room and a kitchen/diner on the ground floor and a small back yard. A stair lift provides access to the upper floor. There is no dedicated parking for the home though parking is available on the street. The weekly fees for this service are calculated on an individual basis depending upon the service user’s support needs. Information relating to the services provided by the Michael Batt Foundation can be obtained from their Head Office at Third Floor, Poseidon House, Neptune Business Park, Cattedown, Plymouth, PL4 OSJ, telephone number 01752 310531. 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. Preparation for the inspection included analysis of the CSCI Annual Quality Assurance Assessment, the last inspection report, and contacts with the home over the last 12 months. An inspection plan was developed from this information. The inspector was in the home from 9.45am to 3.45pm on 29/11/07, and met with the acting manager and the staff on duty. A meeting also took place on the 11/10/07 at the organisations Head Office in Plymouth regarding inspection of personnel files. The following methods were used to carry out the inspection. The care of two people that use the service was tracked during the inspection. The inspector met both these people on the 29/11/07. Staff personnel and training files were sampled during the Head Office visit. We toured the building during the inspection. An opinion on the service was sought from Plymouth Social Services, and from the Plymouth Community Learning Disability Health team and their responses were positive. Various areas of documentation were inspected to evidence compliance with the National Minimum Standards. Documents inspected included assessments of peoples’ needs and their care plans and risk assessments, various records including medication administration records, staff records, and health and safety records. All the information gathered during the inspection was considered in the writing of this report. What the service does well: The house is comfortable and warm. There is plenty of good food. People have enough things to do to be happy. There are always enough staff to help and people get all the help they need. Each person can have their room just as they want it. The staff know how to help people and the staff do their best. 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 6 The staff are safe to be with. If a person has a problem it is easy to get help. If you want to live there the staff will make sure you can find out all about what it is like. 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. 46 Grenville Road DS0000049889.V347915.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 46 Grenville Road DS0000049889.V347915.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): 1,2,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s pre-admission processes ensure that people that are considering using the service are provided with information about the home as well as having the opportunity to experience life in the home before admission. This enables them to make a properly informed decision. EVIDENCE: There have been no admissions to the home since the last inspection. The Foundation has an appropriate admission policy and procedure. People that have been newly admitted to other homes managed by the Foundation have thorough pre admission assessments in place. The pre-admission process thoroughly explores a persons support needs before they are offered a place at the home and each person is enabled to visit the home on several occasions to meet with the other people that live there and the staff. The Foundation provides a written language Service User Guide. The Guide is also available in other formats such as on audio-tape and in pictorial form. Each person that is considering using the service is supported to make an informed choice based on the information in the Guide, from visits to the home and from explanations from the staff. 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 9 Each person that uses the service at present has an individualised version of the Service User Guide or ‘My Home’ booklet, using mostly photographs and symbols as well as some written language. 46 Grenville Road DS0000049889.V347915.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people that use the service are enabled to participate in, and make decisions about, all aspects of their lives. EVIDENCE: Both people are involved and consulted on the day to day running of the home, independence is promoted and people are encouraged and enabled to do as much as possible for themselves. All the routines and activities were centred on peoples’ needs and choices. Staff supported people to make decisions about their lifestyle and activities both inside and outside the home. The staff are fully aware of the needs of each person and these were adequately documented in each persons support plan. Major developments are underway to redevelop care planning. One person now has a care plan that mostly uses photographs to communicate its content in order that it information can be more easily accessed by its owner. The assessment and care plan for the other person that uses the service is being redeveloped in 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 11 relation to their communication needs. When complete this document will be extremely helpful to staff providing consistent person centred care. Some care planning was general and lacked some detail. Comprehensive and detailed care planning will assist staff to provide consistent support to the people that use the service. The acting manager and staff said that any restrictions on choice or freedom had been agreed with the person affected and other people involved in the person’s care. Any restrictions in place were made to protect the service user’s health and safety. Not all the restrictions in place had been documented. Assessment of peoples individual risks were generally good but those missing included medication administration, use of a bed guard, use of a motion sensor, and locking away sharp knives. Though the acting manager could clearly state how these issues would be managed it was recommended that these procedures should be documented. It was noted that neither person that uses the service has an up to date list (inventory) of their personal belongings of value. The service was advised to maintain this record to ensure that there is always an accurate record of each person’s personal items of value. People that use the service are expected to pay for personal items and public transport. The organisation provides additional money for leisure activities and some travel. 46 Grenville Road DS0000049889.V347915.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. The people that use the service can learn life skills, attend clubs, participate in community and leisure activities, choose their own daily routines and enjoy food of their choice. EVIDENCE: Discussions with one of the people that uses the service, the Acting Manager, and the staff on duty together with the activity planned and recorded showed that the people that live at 46 Grenville Rd are enabled to live as full a life as possible and had opportunities for personal development. People that live at the care home are encouraged to participate in domestic activity in the home and to take part in leisure activities of their choice. There is no expectation that people will always do domestic activities such as preparing food, drying up after a meals or laundry. Some people that live at the home enjoy doing domestic tasks, as they feel more valued by completing these activities. 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 13 The home does not provide transport as people are either encouraged to use public transport or staff cars. One person uses the bus to regularly visit clubs in Plymouth twice a week and staff cars to visit another club in the evening once a week. Risk assessment documents showed that people are being supported to develop new skills towards independent activity outside the home. It was seen during the inspection that the people that live here feel very ‘at home’ and are empowered to make decisions. The organisation pays for staff car mileage. Some of the things people that use the service enjoy doing include shopping, eating out, visiting clubs, swimming and going to the beach. Both people were supported to go on their own individual holidays in the UK this year. People participate in food preparation depending on their abilities. One person makes their own meals, drinks and snacks. People that use the service are involved in writing the weekly menu plan and doing the main weekly shopping for the group. Both people that live at the home at present enjoy eating together and preparing communal main meals. Both lunch and breakfast are to peoples’ individual choice. Both people have some of their own individual food stocks such as fruit, breakfast cereal, yoghurts and snacks. Contact with relatives and friends is encouraged and there are no restrictions on visitors coming to the home. 46 Grenville Road DS0000049889.V347915.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. People that use the service receive support in the way, and at the time, that they want and need. Health care needs are addressed as soon as they are identified. EVIDENCE: Both of the support plans belonging to the two people that live at the home were inspected. These provided clear descriptions of personal, emotional and health care needs. Comprehensive and detailed care planning is important to ensure that the support team are fully aware of each person’s specific needs and can respond in a consistent manner. Discussion with people that use the service and staff confirmed that external health support and guidance is sought when necessary from health care professionals. Good records of health appointments and ill health are kept. Both people access Occupational Therapy, Physiotherapy, dentistry, optician and chiropody support as necessary. 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 15 Through observation it was clear that the timing of the delivery of personal care is flexible and is the choice of the person receiving the support. People receive personal care from a staff member of the same gender. Interaction between the people that live at the home and the staff, and acting manager, was observed throughout the day. There was constant communication and response from the staff who showed great respect for the people they were supporting. Peoples’ dignity is being well maintained by the staff. A monitored dosage system is used to administer medication that is in the safekeeping of the care home. This medication was locked away safely and tidily. There is a list (profile) of each person’s medication on file. Medication Administration Records were well maintained. One person is empowered to, take a responsible role in the administration of his medication. After taking the medication they are assisted to sign an administration record sheet to indicate that they have taken their medication. 46 Grenville Road DS0000049889.V347915.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. People that use the service are protected from abuse, neglect and self-harm. People that live at the home can be confident that the Registered Provider always deals with complaints or concerns seriously and takes action quickly. EVIDENCE: The home has a complaints procedure. The organisation has also produced the complaints procedure on audiotape and in a pictorial/symbolic format. Each person living at 46 Grenville Rd has their own accessible format complaints procedure in a photograph based format. Discussion with staff confirmed that people could raise any issue at any time and this would be dealt with immediately. All the staff have attended training in adult protection. This ensures they are aware of their responsibilities should they suspect a person is at risk of abuse. 46 Grenville Road DS0000049889.V347915.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): 24,25,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is satisfactory, providing the people that live at 46 Grenville Rd with a comfortable and homely place to live. EVIDENCE: The home is comfortable and clean. Each person has a single bedroom on the 1st floor, neither of which had en suite facility. Only one of these rooms contained a wash hand basin. Each bedroom is individually furnished, is comfortable, and contains many personal possessions. All the bedroom doors were fitted with appropriate locks. Both the people that use the service at present hold keys to both their bedroom door and the homes front door. This ensures that their rooms remain private and their possessions secure and that they have greater control over their lifestyle. The third bedroom is presently used as an activity room. Some of the things it contained were a large table covered in jigsaw puzzles, a television and a well used exercise bike. At previous inspections people confirmed that they had chosen their bedroom decoration and furnishings. 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 18 The home had a bathroom on the 1st floor containing a bath with a hoist, and a toilet. There was also a separate shower room with a toilet. The bathroom/toilet doors have been fitted with bolt locks. The acting manager said that these locks were the most appropriate type to be in place. It was advised that the reasons for these locks being in place should be documented in each persons care planning. The shared rooms on the ground floor are a kitchen/diner, a large front lounge room and a sensory/staff sleeping in room. The sensory room has a giant beanbag, bubble tubes and a light projector. The front lounge was a pleasant comfortable room with good quality furnishings. It had just been decorated for Christmas at the time of the inspection. The kitchen dining room area is a pleasant and comfortable place to sit and take meals. It was also seen to be the hub of the household where people like to sit and be together. Infection control practices are good and items of personal protective equipment, such as disposable gloves, were easily available. The laundry facilities are in a utility room accessed from the back yard. Guidelines are available on the disposal of clinical waste and the procedures in use are effective. The building has a large accessible concreted rear yard. There was nothing in this area to make it a pleasant place to sit outside. The service is advised to make this area a pleasant area for people to use. The home has various aids and adaptations including a ramp to the front door a stair lift, bath hoist, and toilet frame, to assist with the support of a person that uses the service who has restricted mobility. Both hoists are regularly serviced and documentation about this was seen. 46 Grenville Road DS0000049889.V347915.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, 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. Recruitment processes are robust and people that use the service benefit from well supported staff that have a good understanding of the needs of the people that use the home. EVIDENCE: The acting manager confirmed that the people that use the service have an appropriate level of support. There is a minimum of one member of staff on duty throughout the day and a single member of staff sleeping in. However this is supplemented by some additional hours from the Foundations ‘bank’ staff, from the acting managers hours and from the domestic /support worker. In practice this results in there often being 2 staff on duty during daytime hours. This ensures there are adequate hours for both the people that use the service to go out on activities and have their needs met. The organisation operates an ‘on call’ system whereby members of the management team are available to provide support both in and out of office hours. 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 20 The Foundation has a department that ensures recruitment practices are safe. A sample of staff files were examined and showed a robust recruitment procedure. All the required information was available, including Criminal Record Bureau checks and 2 written references, ensuring as far as possible only suitable staff are employed. Documentation showed records of staff meetings. Regular individual supervision sessions are taking place. Staff are also supervised informally while supporting the people that that use the service. The supervision meetings addressed the principles and values of the Foundation, staff performance and training and development needs, as well as day-to-day support issues. The Foundation has a designated staff member to coordinate and arrange training, to maintain an overview of what the organisation requires, as well as ensuring that individual staff members receive the training they need. The foundation is now providing training to other organisations in the nationally recognised Learning Disability Qualification (LDQ), which has replaced the Learning Disability Award Framework (LDAF) levels 1 2. All new employees are being trained in this qualification and it is being backdated to any existing members of staff who do not hold LDAF1 2. The LDQ covers basic training on topics such as social role valorisation, person centred planning, human development, adult protection, emergency first aid, and health and safety ensuring staff members have the skills and confidence to support the people that use the service on a day-to-day basis and also at times of crisis. The majority of staff are either enrolled on or have completed the LDQ or have completed LDAF levels 1 2. Both courses are nationally recognised qualifications. None of the care staff have undertaken basic formal medication administration training. It was advised that all members of staff receive training in this area. It was also advised that all staff under take basic care training. Two of the team of three that provide support at 46 Grenville Rd are qualified to LDAF level 2 or above. 46 Grenville Road DS0000049889.V347915.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): 37,38,39,40,41,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Managers approach is open, inclusive and positive, providing clear leadership and guidance. Empowerment and enablement of people that use the service is the focus of the organisation. Peoples’ health and safety is generally well managed and their welfare is promoted. EVIDENCE: At present the home is being managed by an Acting Manager, Lauren Young. She has completed the “Humanistic Approach to Support” Course, the LDAF 3 course which follows a person-centred philosophy of care and support. Lines of accountability were clear and the organisation has a management structure that enables it to cover absences when required, and provide an effective ‘on call’ system to support staff. 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 22 Tests and checks of fire safety equipment had been carried out as required. Staff have completed training in fire safety, first aid, food hygiene and health and safety ensuring they have the skills to deal with emergencies. Accident records were not accessible during the inspection at the home. The original copies of the homes accident reports are sent to the organisations head office. The organisation is advised to retain these at the home and to send a copy to head office. Environmental risk assessments were not adequate to demonstrate individual assessment of each unrestricted window above ground floor level, each uncovered radiator and each hot water outlet available to people that use the service. In general environmental risk assessments needed to be improved. The Foundation has a Quality Assurance Auditor who is responsible for assessing whether the services provided meet peoples needs to their satisfaction as well as ensuring their safety and that of the support staff. These assessments are detailed and include all aspects of a person’s personal, health, emotional and social support needs. The organisation ensures that people that use the services are approached for feedback on their service in a manner appropriate to their communication abilities. There is a draft Quality Assurance policy and procedure. As part of the Quality Assurance process relatives of the people that use the service, and professionals involved with each persons support, are approached to give their opinions on the service provided. The results of the quality assurance process were delivered to the acting manager on the day of inspection and were aimed to deliver the highest quality service, within financial constraints, to the people living at 46 Grenville Rd. The results of the process will be shared with the people that use the service and their relatives or representatives. 46 Grenville Road DS0000049889.V347915.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 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 3 27 3 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 3 2 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 3 3 3 3 2 X 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA42 Regulation 13 Requirement Individual risk assessments must be carried out for all window openings above ground floor level, all uncovered radiators and all non-adapted hot water outlets. (This requirement was verified as complete, before publication of this report). Timescale for action 14/01/08 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 Refer to Standard YA6 YA42 Good Practice Recommendations Care planning should comprehensively document all risk assessment and restrictions of choice. The fire evacuation procedure should be reviewed and any consequential action necessary taken to ensure risk is managed at an acceptable level. 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 46 Grenville Road DS0000049889.V347915.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!