Care Home: 97 Monmouth Road

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What the care home does well The residents living at Monmouth Road are supported by experienced staff who know the needs of the individual residents and are able to provide appropriate support. The staff have a good knowledge and understanding of resident`s complex and sometimes challenging needs and have the skills to meet those assessed needs. Individual care plans were available that show how residents assessed care needs are to be met. There were excellent examples during the visit of how the support workers clearly understand how each resident communicates their needs and wishes and this was further endorsed with written communication profiles in the residents` individual records. Residents receive good standards of personal and health care and benefit from a healthy and balanced diet. The staff ensure that there is very close liaison and regular communication with residents` families and families are invited to attend the regular house meetings.The staff ensure that prospective residents have a comprehensive transition programme that includes several visits to the home prior to the final decision to move in. The staff continue to be well supported through the quality of training received. There was a sense of staff working together during the inspection and there was a relaxed but vibrant atmosphere with the support workers engaging positively with all the residents. Community based activities are valued by the staff and the residents enjoy a high presence in their local community accessing a range of social and recreational facilities. What has improved since the last inspection? Since the last inspection a manager has successfully been appointed and registered with the Commission for Social Care Inspection. The quality of the records and the up to date information provided in the Individual Service/Care Plans accurately reflects the wishes and needs of the service users living at Romulus. All the records checked throughout the inspection process had been signed by staff and were kept safely within the home. Some equipment, and fittings have been replaced e.g. new front door, freezer and redecorating in the communal areas is work in progress. The majority of requirements from the previous inspection report have been addressed. What the care home could do better: There was significant evidence that the support workers are working hard to continue to improve, and develop the service. However, the organisation needs to make every effort to enable residents and or their representatives and staff to express their views formally through the quality assurance procedures concerning both the current services and the future plans for the development of the service and facilities at Monmouth Road. It is important each service in the network of Cheshire homes has its own identity and is personalised to the specific services and facilities according to the group of residents living in each home.The registered manager should be given full access to the budgets, which affect the residents and the management of the home and should be allowed to manage all aspects of their home. CARE HOME ADULTS 18-65 Monmouth Road (97) Dorchester Dorset DT1 2DF Lead Inspector Marion Hurley Key Unannounced Inspection 5th November 2007 10:00 Monmouth Road (97) DS0000026755.V353798.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 Monmouth Road (97) DS0000026755.V353798.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. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Monmouth Road (97) Address Dorchester Dorset DT1 2DF 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) 01305 266430 01305 250138 keeley.grennan@lc-uk.org www.leonard-cheshire.org.uk Leonard Cheshire Jane Ann Street Care Home 3 Category(ies) of Learning disability (3), Physical disability (3) registration, with number of places Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd August 2006 Brief Description of the Service: 97 Monmouth Road is a care home registered to provide care and accommodation to three people who have learning disability. The home is one of seven similar services in Dorchester that are owned and operated by the Leonard Cheshire Foundation, a not for profit organisation providing services to people with disabilities. The property is a semi-detached house, located in a quiet residential street, close to Dorchester town centre. All service users have single bedrooms, and share the communal lounge, dining room, kitchen and bathroom. There is a large rear garden with a summerhouse utilised as an art room by residents from all the Leonard Cheshire Homes in the Dorchester locality. The home is staffed 24 hours a day, with usually two staff during the day and one member of staff on duty in the evening and sleeping in at night. Day activity programmes are arranged for residents, which include accessing local leisure and community facilities. Fees are individually negotiated according to the residents needs. Copies of inspection reports are available upon request from the Leonard Cheshire Home administration Office in Dorchester. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken as part of the statutory inspection process in accordance with the Care Standards Act, 2000. All key standards were assessed according to the Care Home for Adults (18-65) National Minimum Standards. The time spent on the inspection process totalled ten hours, four of which were spent at the home. The purpose of the inspection was to make sure the home was being run for the benefit of the people who live there and in accordance with statutory requirements and regulations. The residents have varied communication needs, some of whom have verbal needs and communicate through sounds, gestures and actions. The inspection included spending time talking with, and in particular observing residents, and their interactions with the support workers. Documentation examined included the resident’s care/service plans, staff rota and medication records and all records pertaining to health and safety. The inspector thanks all the residents and the staff on duty for their help and support in the process of this inspection. What the service does well: The residents living at Monmouth Road are supported by experienced staff who know the needs of the individual residents and are able to provide appropriate support. The staff have a good knowledge and understanding of resident’s complex and sometimes challenging needs and have the skills to meet those assessed needs. Individual care plans were available that show how residents assessed care needs are to be met. There were excellent examples during the visit of how the support workers clearly understand how each resident communicates their needs and wishes and this was further endorsed with written communication profiles in the residents’ individual records. Residents receive good standards of personal and health care and benefit from a healthy and balanced diet. The staff ensure that there is very close liaison and regular communication with residents’ families and families are invited to attend the regular house meetings. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 6 The staff ensure that prospective residents have a comprehensive transition programme that includes several visits to the home prior to the final decision to move in. The staff continue to be well supported through the quality of training received. There was a sense of staff working together during the inspection and there was a relaxed but vibrant atmosphere with the support workers engaging positively with all the residents. Community based activities are valued by the staff and the residents enjoy a high presence in their local community accessing a range of social and recreational facilities. What has improved since the last inspection? What they could do better: There was significant evidence that the support workers are working hard to continue to improve, and develop the service. However, the organisation needs to make every effort to enable residents and or their representatives and staff to express their views formally through the quality assurance procedures concerning both the current services and the future plans for the development of the service and facilities at Monmouth Road. It is important each service in the network of Cheshire homes has its own identity and is personalised to the specific services and facilities according to the group of residents living in each home. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 7 The registered manager should be given full access to the budgets, which affect the residents and the management of the home and should be allowed to manage all aspects of their home. 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. Monmouth Road (97) DS0000026755.V353798.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 Monmouth Road (97) DS0000026755.V353798.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their needs assessed before admission to the home so that staff can provide individually tailored care. Their families and significant others are given sufficient verbal information about the home so that they can be assured that the home can meet the needs of the prospective resident. The home needs to develop a Statement of Purpose, and Service User Guide, which are specific to Monmouth Road to ensure prospective residents, and their representatives have relevant written information to make an informed choice. EVIDENCE: Cheshire Homes reviewed and issued a generic Statement of Purpose in May 2007 and this now needs to be adapted to each individual service /home. The documents should identify the specific services and facilities available in each home for the service users and their representatives. A service user guide has recently been produced and this again needs to be personalised to each home. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 10 The staff confirmed that the home has not admitted anyone for several years. However there is currently a person considering a move from another Cheshire Home and this prospective resident and their representative will need to be assured that the admission procedures are carefully followed despite the person already being known to the Cheshire Home Services. The manager emphasised the importance in a small home of making sure that the new person would be compatible with the people already living at the home and already the transition process has begun. This has included a series of visits, and outings with other members of the household and an overnight stay. The support workers confirmed that people offered a place at the home would be supported throughout the admission process and care taken to make sure they settle into their new environment. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 11 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. Detailed information about residents assessed and changing needs as well as areas of risk are included within their service/care plans and this ensures staff have the necessary information when caring and supporting the residents. EVIDENCE: Individual service/care plans have been completed for each person and explore all aspects of their daily life including areas of risk. Some residents living at the home have complex emotional and physical needs and both support workers and the manager stated how as a team they work hard to ensure the residents receive a consistent approach to help them manage their lifestyles. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 12 Staff said they seek advice and support from health & social care professionals as appropriate and specialist assessments were seen with the resident’s individual records. The plans are presented in the first person and focus on how each individual chooses to live their life, what their preferences are, their daily routines, what support they need and how they would like it provided. Information was examined for one resident who needs have recently changed and the records showed that these were being monitored and assessed and updated to reflect the changes. The support workers described how they have discussed with the manager the most appropriate way to support the resident during this period of change. The manager hopes to develop the individual service /care plans into positive person centred plans which will include personal profiles and daily routines for all the residents. The plans are well present and easy to read however the plans are let down by the use of some very dated forms representing the risk assessments which still refer to people as “clients” and which do not link practically into the care/service plans nor are specifically related to the individual and their lifestyle and abilities. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have regular opportunities to use local facilities with staff support, which they seem to enjoy, along with a range of social trips. The provision of social and leisure activities is valued at the home. The daily routines within the home are flexible and promote individuals choice. Menus provide a healthy balanced diet promoting the residents’ health and general well being. Residents are supported to have control over their lives within the abilities to safely do so. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 14 EVIDENCE: Each person has an individual service plan and a separate diary, which shows his or her weekly activities, including trips out. The home has a vehicle, which is used to take people on both planned and spontaneous outings to local places of interest. The needs of the people living at Monmouth Road are such that they require assistance with all aspects of daily living. Staff said residents’ relatives and friends are able to visit the home at any reasonable time and are made welcome and the residents’ records included details of family contacts. Staff described supporting families and residents to ensure positive contact time during the visits and where necessary staff will initiate visits. The shopping for the home tends to be done at the local supermarket and this is based on the weekly menu, which is devised from the residents likes and dislikes and the need for a suitable soft diet for one person. Some shopping is done locally and staff may like to think of accessing other local suppliers and possibly farm shops and farmers markets with the residents. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 15 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. Residents’ physical and emotional needs are met and the residents receive personal support in a manner, which promotes their privacy, dignity and independence. Residents’ personal and healthcare needs were described in their individual plans and provided staff with clear instructions and information on the type and level of support and personal care each person needs to ensure staff can meet their needs safely. Corporate medication procedures ensure that staff adhere to the safe administration of medication to protect the safety and welfare of the three vulnerable residents living at Monmouth Road. EVIDENCE: During the visit staff were seen offering appropriate support to the three residents e.g. accessing the bathroom and prompts and discreet supervision during the mealtime. The records illustrated and staff described the level of Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 16 support each person required demonstrating their practical understanding of each person’s individual needs and how these are met on a daily basis. Residents are supported to attend all routine health check ups in addition to any specialist support from health and social care professionals. A separate record of visits to various healthcare professionals is kept and the outcomes of consultations recorded. The medication system in use at the home was examined. Medication is stored appropriately at the home in a securely locked cupboard. All labels were intact on bottles and boxes and these could be clearly read. All medications were for named individuals. The MAR (medication administration record) sheets were fully completed. Staff confirmed they had been appropriately trained in the safe handling of medicines and the staff training records validated this information. No resident has the capacity to manage his or her own medication safely. Throughout the visit staff were observed caring for the residents and responding to their requests for help. Staff were aware of the likes and dislikes of the residents and how they wished to be cared for. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 17 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. Cheshire Homes has corporate complaint polices and procedures which ensure residents would be listened to and action taken to deal with complaints promptly. Access to the complaints procedure is available in the home which enable visitors to raise issues of concerns on behalf of the residents Residents and their representatives can expect staff to respond to their concerns, which may not always be expressed verbally. There are adult protection procedures that promote the protection of residents from harm or abuse. EVIDENCE: Cheshire Homes has corporate policies and procedures for dealing with complaints. There have been no recorded complaints since the last inspection in December 2006. Staff training records confirmed that all staff had received “Safeguarding Adults” (adult abuse) training and “team-teach” training (specialist intervention techniques). The support workers demonstrated their knowledge of the safeguarding adult procedures and could describe the appropriate responses, recording and reporting with reference to protecting vulnerable Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 18 adults. There have been no “Safeguarding Adults” investigations during the 12 months previous to this inspection. From discussions with the support workers it was clear they have a good understanding of the homes whistle blowing policy. Staff felt confident that residents would and do express their views by gestures and various facial expressions and it was evident from talking with the staff that they knew and recognised many of these differences and would endeavour to establish the problem and then resolve it for the resident. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Several improvements have been made to the environment, however further improvements are still required to ensure the safety, comfort and the creation of homely environment for the people who live and work at Monmouth Road. EVIDENCE: The home does not employ any additional staff to complete domestic tasks but the care team clearly take a pride in the home and see it as their responsibility to ensure it is kept clean. Cleaning materials were safely and appropriately stored. Appropriate protective clothing was available and staff said there was always an ample supply. Each person has their own bedroom and these had been decorated to reflect their different personalities and interests. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 20 There is a good size garden at the rear of the property, which is accessible to residents. At the time of the visit the ground floor was being redecorated however it was possible to observe that standards of cleanliness and hygiene at the home were being maintained. The washing machine has a sluicing programme and the support workers described good practice regarding infection control and managing infected materials safely. There were no unpleasant odours were noted during the inspection visit however; staff said the washing machine had a leak and the outlet smelt very unpleasant at times. Since the last inspection a new front door has been fitted and new flooring in the dining room. When the remainder of the decoration has been completed it is hoped this will improve the overall décor of the home making the internal rooms much lighter and brighter. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by thorough staff recruitment and selection procedures. Staff are provided with regular staff meetings, training and supervision, which ensures they can meet the support needs of each person who lives at Monmouth Road. EVIDENCE: There is a core of well-established staff with varying abilities that are skilled and experienced to meet the needs of those living at the home. Several members of the staff team have worked at the home for a number of years and provide consistency and an excellent understanding of each person’s support needs. This small but established team are committed to ensuring the residents living at the home receive the best possible quality of care and support. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 22 Discussions with staff members and observations of their work practice demonstrated that they were approachable, good communicators and were very comfortable with individuals living at Monmouth Road who were at ease and relaxed in their company. The staff said they felt were supported by their manager who was a “good champion” for their home. The staff on duty during the visit were confident in their roles and helped the inspection process by explaining and discussing their knowledge of care plans, reviews and policies and procedures and providing records where necessary. Regular staff meetings are held, recorded and appropriate subjects discussed. Staff recruitment and selection procedures are thorough and include a formal interview, the taking up of two written references and a Criminal Record Bureau check before the new member of staff can start work. The rota was examined during the visit and showed that there is normally a minimum of two staff on duty during the day with one person covering the overnight sleep in duties. The rota showed that because of sickness, annual leave and staff recruitment the Registered Manager has to cover any gaps in the rota which can create additional pressure to complete all the managerial responsibilities and roles. Staff recruitment and selection procedures are thorough and include a formal interview, the taking up of two written references and a Criminal Record Bureau check before the new member of staff can start work. Two staff files were randomly selected and were checked to verify this standard. The training records of two staff were reviewed and found to be comprehensive and up to date. Two personnel files were also checked and these have recently benefited from being reorganised, both were well presented. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified and competent to run Monmouth Road and meet the aims and objectives of the service to ensure the welfare and positive lifestyles of those living and working within the service. The manager is keen to develop their leadership skills and promote a person centred approach and this is clearly communicated through the service. There are systems in place designed to promote the health and safety of both individuals and staff. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 24 EVIDENCE: Since the last inspection the registered manager has been appointed and successfully completed their National Vocational Training level 4 (NVQ). The management approach is open and positive with a good sense of direction and leadership and staff stated that they felt well supported and that it was clear the registered manager was keen to ensure the home is run in the best interests of the residents. Regulation 26 visits have been regularly carried out and the named person has checked a variety of records, discussed issues with staff, checked the environment and provided written reports. Residents’ finances were discussed and the records checked and found to be accurately maintained. The service manager responsible for the Cheshire Home services in the Dorchester locality stated that at this stage the services and individual homes do not have a current quality assurance system. Such a system is needed to ensure that all stakeholders are consulted about the overall quality of care the homes provide. It is very important that residents and or their representatives are involved in the self-monitoring and quality assurance procedures. A senior member of staff now undertakes a monthly audit of a specific area of practice, for example the procedures for managing and handling resident’s laundry, safe handling and administration of medication and these are practical ways to ensure quality is monitored and maintained. Policies and procedures are in place to ensure the health and safety of people living and working at the home. These are reviewed on a regular basis to ensure they comply with present legislation. The AQAA completed by the manager, indicated that equipment was being serviced and checked at appropriate intervals and procedures were in place for the maintenance and servicing of appliances and equipment promoting and protecting the health and safety and welfare of staff and residents. Fire alarm tests were carried out weekly and fire training records were up to date with all staff attending as required. All staff had received health and safety training, moving and handling, food hygiene and fire training. Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 4(1)(2) Requirement The service must develop a Statement of Purpose & Service User Guide, which clearly sets out the role and responsibilities of the provider and details the services and facilities available specific to the home. Please note this is work in progress. All parts of the home must be kept in good repair. Effective quality assurance and quality monitoring systems, based on seeking the views of service users, must be in place to measure success in achieving the aims, objectives and statement of purpose of the home. A new timescale has been agreed. Timescale for action 31/12/07 2. 3. YA24 YA39 13(4)(a) 24 (1) (2)(3) 31/12/07 31/12/07 Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 27 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 YA24 Good Practice Recommendations It is recommended that the furniture in the communal areas being considered for replacement to match the new lighter décor e.g. television in the lounge, sideboard in the dining room and replacement nit in the kitchen) Cheshire Homes need to consider what is an appropriate amount of relief “care hours” the registered manager should undertake to compensate for staff sickness or annual leave and how this may affect other responsibilities. 2 YA32 Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Monmouth Road (97) DS0000026755.V353798.R01.S.doc Version 5.2 Page 29 - 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!