Care Home: Cheshire Drive

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What the care home does well The AQAA states: "We place the needs and wishes of the people we support at the centre of what we do. The people we support live ordinary lives and take part in ordinary activities. We have dedicated and competent team of staff who are very committed to improving the lives of the people we support. We have built effective relationships with external professionals and the families of the people we support." The ethos of Cheshire Drive is that each person`s views are valued. The information in care plans, observation of the staff and residents, and what people wrote in the Have Your Say surveys, all confirmed that everyone is encouraged and supported to make their views and wishes known, and to make decisions about their lives in the home. One relative said, "We are happy that our [name]is looked after very well." A member of staff said that what the home does well is, "To support and encourage people we support to access different activities and services." The vision for the service is to support people to become more independent and to move on to live independently in the community. The first steps have been taken towards this goal, with detailed plans for three people to work towards moving on. What has improved since the last inspection? All the requirements from the last inspection report have been met. The atmosphere in the home is more homely, with new light coloured carpets and better lighting. The care plans describe clearly what each person wants to do, and how they plan to do it. CARE HOME ADULTS 18-65 Cheshire Drive 53-55 Cheshire Drive Leavesden Watford Hertfordshire WD25 0GP Lead Inspector Claire Farrier Unannounced Inspection 9th June 2008 12:30 Cheshire Drive DS0000039939.V366107.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 Cheshire Drive DS0000039939.V366107.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. Cheshire Drive DS0000039939.V366107.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cheshire Drive Address 53-55 Cheshire Drive Leavesden Watford Hertfordshire WD25 0GP 01923 682671 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) www.pentahact.org.uk PentaHact Limited trading as Adepta Afsaneh Alizadeh Alamdari Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Cheshire Drive DS0000039939.V366107.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th June 2007 Brief Description of the Service: Cheshire Drive is a care home for six people with a learning disability. It is managed by Adepta, which is a private company. The home is a detached, purpose-built, two storey house. It is located on an estate on the outskirts of Leavesden and blends in well with surrounding properties. One of the bedrooms is on the ground floor and has been designed to accommodate a wheelchair user. It has a fully assisted bathroom adjacent. The other five bedrooms are upstairs and can only accommodate ambulant people, as there is no lift installed. The Statement of Purpose and Service Users Guide provide information about the home for referring social workers and prospective residents. A copy of the most recent CSCI inspection report should be made available on request to the home. Information on the fees charged was not available on this occasion. Cheshire Drive DS0000039939.V366107.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. We spent one afternoon at Cheshire Drive, and the people who live there and work there did not know that we were coming. The focus of the inspection was to assess all the key standards. Some additional standards were also assessed. We looked around the home and the garden. We met most of the people who live in the home, and all people completed Have Your Say surveys before the inspection. Two relatives and four members of staff also completed Have Your Say surveys, and we have used the information from these in this report. We visited the home twice before the main inspection to deliver the surveys, and to collect them. We talked to the manager about what we had seen during our visit. The manager sent some information (the Annual Quality Assurance Assessment, or AQAA) about the home to CSCI before the inspection, and her assessment of what the service does in each area. Evidence from the AQAA has been included in this report. We have also looked at the reports of the visits that a representative of Adepta makes to the home. What the service does well: The AQAA states: “We place the needs and wishes of the people we support at the centre of what we do. The people we support live ordinary lives and take part in ordinary activities. We have dedicated and competent team of staff who are very committed to improving the lives of the people we support. We have built effective relationships with external professionals and the families of the people we support.” The ethos of Cheshire Drive is that each person’s views are valued. The information in care plans, observation of the staff and residents, and what people wrote in the Have Your Say surveys, all confirmed that everyone is encouraged and supported to make their views and wishes known, and to make decisions about their lives in the home. One relative said, “We are happy that our [name]is looked after very well.” A member of staff said that what the home does well is, “To support and encourage people we support to access different activities and services.” The vision for the service is to support people to become more independent and to move on to live independently in the community. The first steps have been taken towards this goal, with detailed plans for three people to work towards moving on. Cheshire Drive DS0000039939.V366107.R01.S.doc Version 5.2 Page 6 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. Cheshire Drive DS0000039939.V366107.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 Cheshire Drive DS0000039939.V366107.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 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has sufficient information on residents’ needs and access to appropriate services to enable their needs to be met. EVIDENCE: Five people live in the home, and there is one vacancy. No-one has moved into the home in the last four years, but according to the Annual Quality Assurance Assessment (AQAA), “If there were to be any new admission an assessment of the referred person would be made in conjunction with the care management team to identify if the person can meet the needs of the person or not. There is an organisational policy in respect of this.” The surveys that we received from relatives stated that the care home meets the needs of their relative, and meets the different needs of people. The staff who we spoke to during the inspection said that they have sufficient information and training to enable them to meet the residents’ needs. The Statement of Purpose for Cheshire Drive needed to be reviewed and updated, because some of the information it contained was out of date, including information about the company, and the details of the staff in the home. It was updated following the inspection, and a copy was sent to the Commission. The home provides a service for people with learning disabilities, with the aim of supporting them to become more independent and to move on Cheshire Drive DS0000039939.V366107.R01.S.doc Version 5.2 Page 9 to a more independent life in the community. The Statement of Purpose should clarify this, and contain appropriate terms and conditions for the services provided in the home. Cheshire Drive DS0000039939.V366107.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home are actively involved in their own care planning and are consulted on every aspect of community life in the home. The outcome for people in the home may be excellent if their aims for independent living are achieved as planned. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) states, “We support people to take risks and live as independently as they can. Staff are aware of people’s abilities to make choices and decisions and will empower people to make as many choices as possible.” The staff who we spoke to said that the care plans provide them with good information on each person’s needs, so that they are able to provide a good quality of care in the way that each person wishes. One member of staff who completed a survey for this inspection said that what the service does well is to recognise the person centred approach. Most of the surveys from the people who live in the home said that they are involved in making decisions in the home. We looked at the files of two people, which show what care is provided for them and how it is recorded. The care plans are Cheshire Drive DS0000039939.V366107.R01.S.doc Version 5.2 Page 11 written in a person centred format, which shows that people are involved in making decisions about their care and their lives in the home. The care plans have good details of how each person makes decisions and the opportunities that they have to make decisions, with information on how they can be involved and the support that they need. This includes examples of choices that each person can make independently, which other people should make (for example how much rent they pay), and which are made jointly by the person concerned and other people (for example who live with and where to go on holiday.) There are risk assessments in each care plan, which provide guidance to staff in supporting people to take risks as part of an independent lifestyle. One person has a particularly good risk assessment for travelling independently on public transport. It details each step of the route, and includes photographs of each step to enable the person to fully understand the process. The support worker who developed this risk assessment with the person has won a staff award for the programme. Each person has a monthly meeting with their key worker to look at and review their care plan and their life in the home. Each person is involved on planning their own annual care planning meetings. One person chose to have their care planning meeting at a local club, and invited the people that they wanted to be there, including relatives and friends from the club. The AQAA states that as a result of listening to the people who live in the home they have organised holidays and improved the environment. They are in the process of reviewing people’s placements with the aim of supporting some people to move on from Cheshire Drive. The care planning meeting for one person looked at where they want to live, and what they need to do to be ready to move out of the home. We spoke to two people about their plans, and both had clear ideas for what they want to do and how this can be achieved. Further practical work will be needed in order for them to achieve their goals, in particular in identifying and resourcing the places they will live and the support they will need. Two people already have many of the skills that they will need to live independently. One goes out independently and works as a volunteer, another cooks independently in the home and the staff are supporting them with a personal relationship. Advocacy is available to assist people to make decisions if needed, and this service has been used to assist one person in the home. Cheshire Drive DS0000039939.V366107.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 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who live in the home are supported to live full and active lifestyles, and to develop their skills for independence. EVIDENCE: The staff support and encourage the people who live in the home to develop and maintain their independence. The care plans have a focus on maintaining each person’s independence (see Individual Needs and Choices.) Each person has a very individualised weekly programme, some people attend day care, one person has voluntary work. One has chosen not to attend any formal activities during the day, but has an active programme of things that they like to do in the home and the community. During our visit to the home this person went shopping, and later went o the local pub with other people in the home. They chose which pub to go to, and after discussion agreed to walk there and to travel back in the home’s vehicle. Another person had gone to Brighton for the day with their key worker and a friend. They had decided on this on the spur of the moment as it was a fine summer day. Everyone is encouraged and Cheshire Drive DS0000039939.V366107.R01.S.doc Version 5.2 Page 13 supported to choose holidays during the year, either with their families or with staff from the home. The staff surveys said that what the home does well is to support and encourage people we support to access different activities and services and to have good contact with the families and help to maintain it. Everyone has families or friends who visit them or who they visit regularly. The surveys from relatives said that the staff support people to live the life they choose. “They are always concerned about [name] faith and religion. They do at times take them to temple.” “They always think of their interest and accordingly do what is necessary. They enjoy social, eating out, long drive, train rides. Their programme is adjusted to their interest.” Two people have close relationships with people outside the home, and the staff support them to maintain these relationships. At the time of our visit plans were in place for one of the friends to stay in the home over night, and following the inspection this has happened. During our visit to the home one person prepared a pasta lunch for everyone in the home, with support from the staff but very independently. Some people like to eat together, but others prefer to eat on their own, and may eat at different times. The atmosphere in the home is friendly, but some people do not enjoy each other’s company, and their wishes to eat separately are respected. Cheshire Drive DS0000039939.V366107.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an experienced and enthusiastic team of staff, who have the training and skills to provide a good quality of care for the people who live in the home, and to ensure that individual needs, choices and preferences are met at all times. EVIDENCE: Most of the residents look after their own personal care, and the care plans contain good details of the care needs of those that need some assistance. The Annual Quality Assurance Assessment (AQAA) stated, “Personal care is provided flexibly according to individual needs and preferences. When allocating staff to support people, a great deal of consideration is given to who the people would prefer to support them.” Everyone who completed a survey for this inspection said that they feel well cared for. One relative said that the home looks after their relative well. Another said that their relative had a severe behaviour problem and they have worked well. All the staff who completed surveys feel that they have the right support, experience and knowledge to meet the different needs of the people in the home. Everyone who completed a survey for the people who live in the home said that the staff treat them well and listen to what they say. Cheshire Drive DS0000039939.V366107.R01.S.doc Version 5.2 Page 15 The care plans contain good details of each person’s care needs. The healthcare records seen included references to hospital visits, and contact with GPs and other health professionals. We saw clear guidelines for managing behaviour for one person. This includes the use of physical intervention, and all the staff have had specific training for using suitable physical intervention techniques (SCIP). All incidents have been recorded properly, with full details of any interventions that were used. However the guidelines include some practices that are no longer required, and need to be updated so that the information is not misleading. One person has been seen by the GP due to their weight. This person has a healthy diet in the home, and only has crisps and chocolate once a week when they go to the Gateway Club. It has been noticed that their weight increases when they go on holiday with a relative, but reduces again when they return home. The GP has said that they show no signs of ill health. The home has sound systems in place to manage people’s medication safely. We checked a sample of medication records, which were free of errors, with no signature gaps found on the MAR (medication administration record) charts. Each person has their own medication in a locked cabinet in their bedroom. There have been five incidents of medication being missed during the last year, possibly due to unclear procedures for ensuring that each person has their medication. The procedure for administering medication was rewritten in March 2008. One member of staff administers the medication, and another signs the MAR chart to witness that it has been administered. This should ensure that the risk of errors is minimised. One person had paracetamol in their medication cupboard, but it was not listed on the current MAR chart. On a previous MAR chart the paracetamol had been recorded properly, with the reason why it was administered on each occasion. However there was no clear guidance on whether the person should have one or two tablets when it is needed. This information should be clarified with the GP or the supplying pharmacist. Cheshire Drive DS0000039939.V366107.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home are encouraged and enabled to make their views and concerns known, and appropriate procedures are in place to ensure that they are protected from abuse and neglect. EVIDENCE: Everyone who completed a survey for this inspection said that they feel safe in the home. But two people were not sure who to speak to if they are unhappy. The relatives who completed surveys said that they know how to make a complaint about the care provided by the home if they need to, and the service has responded appropriately if they have raised concerns about their relative’s care. No complaints have been recorded during the last year. There is a Grumbles book, where any concerns are recorded. One person complained that another hit them, and one person complained that another had been in their room. These were addressed by talking to the people involved. The Annual Quality Assurance Assessment (AQAA) stated that staff are trained in the protection of vulnerable adults, and the Hertfordshire policy of Protection of Vulnerable Adults is adhered to. The staff who completed surveys said that they know what to do if a service user, relative, advocate or friend has concerns about the home. Cheshire Drive DS0000039939.V366107.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and well maintained environment for the people who live there, and the staff maintain the home to a good standard of cleanliness and hygiene. EVIDENCE: Cheshire Drive is a detached, purpose-built, two storey house. It is located on a newly constructed estate and blends in well with surrounding properties. The house is owned by a housing association, which is responsible for maintenance and repairs to the fabric of the building. The house is furnished and decorated in domestic styles that produce a homely, comfortable environment, which allows the people who live there to relax and feel very much at home. Everyone has their own room, which is arranged and decorated to reflect their particular interests and tastes. Since the last inspection new carpets have been fitted in the corridor and staircase. The carpet in one of the bedrooms has been changed to laminated flooring to remove offensive odour. A ground floor window has been replaced to increase security for one of the people in the home. The Annual Quality Assurance Assessment (AQAA) stated that in the Cheshire Drive DS0000039939.V366107.R01.S.doc Version 5.2 Page 18 next twelve months there are plans to change the carpets in the bedrooms and sleep-in room, to redecorate the communal areas and bedrooms, and to paint the garden fences and replace trellising. The house is owned by a housing association, which is responsible for maintenance and repairs to the fabric of the building. There have been continuing difficulties with the time that it takes for the housing association to make necessary repairs. The report of the proprietor’s monitoring visit in January states, “A constant battle with the housing association over maintenance. Unless there is a health and safety issue they are very slow to respond.” A meeting has been arranged between Adepta and the housing association to address this. We saw no obvious outstanding maintenance needs during our visit. The home appeared to be clean, and the staff follow appropriate procedures to maintain hygiene and prevent the risk of infection. Cheshire Drive DS0000039939.V366107.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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home are supported by a stable staff team who have the experience and training to understand and meet their needs. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) states, “We have dedicated and competent team of staff who are very committed to improving the lives of the people we support.” The staff rota shows that there are three support staff in the home throughout the day, and one at night. This level of staffing means that the people who live in the home can have individual support to do the things they want to do, in the home and in the community. The staff work 12 hour shifts. This is contrary to the Working Time Directive. However, it means that staff are able to support people throughout the day, for example by taking one person to Brighton for the day (see Lifestyle). No one works more than 48 hours a week. The home has several vacancies, and approximately 30 of the shifts are covered by one or more agency staff. These are experienced in the home, and know the people who live there well. However some concern was expressed by a relative: “The only problem is of staff turnover. By the time [name] gets Cheshire Drive DS0000039939.V366107.R01.S.doc Version 5.2 Page 20 used to the particular staff, we hear that he is transferred or left employment.” The AQAA stated that the level of staff vacancies is a barrier to improvement. However plans for person centred recruitment are ongoing and the anticipation is that all vacancies will be filled by the end of this summer. A deputy manager has recently been appointed. Adepta has introduced person centred recruitment. This includes a person centred job specification for the new and prospective staff, which aims at matching the personality and interests of staff to the people in the home. The people in the home are involved in deciding the sort of people who they want to support them. The ultimate aim is that when people move on from Cheshire drive to live more independently, the staff who know them will be able to move on with them. The manager confirmed that the recruitment procedures followed by the company are robust and that she sees all the information on each applicant during the recruitment process. We looked at two staff files, which contained all the information required to confirm that the person is suited to working in the home. The references and CRB (Criminal Record Bureau) disclosures are stored at Walsingham headquarters, but the manager sees them during the recruitment process. Adepta provides comprehensive training for staff that covers all mandatory training in first aid, moving and handling, fire safety, food hygiene and infection control. Training is also available to meet any special needs such as epilepsy and challenging behaviour. The staff spoken to said that the training and support provided for them is very good. 2 of the 12 support workers have a qualification at NVQ2 or above, and 3 are working towards it. Cheshire Drive DS0000039939.V366107.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed for the benefit of the people who live there, and their views are actively sought and acted on. EVIDENCE: The ethos of the home is that it is the home of the residents, and the staff support them to live their lives as they wish to and to make their own decisions about every aspect of their lives in the home. The manager has twelve years management experience, has obtained NVQ4 in management, NVQ3 in care, and Executive Diploma in Management. An assistant manager was appointed recently, and this has had a good effect on staff morale. One member of staff who completed a survey commented, “I sometimes think my manager is overloaded with work especially paper work and we didn’t have an assistant manager for a long time. Now that we do have an assistant manager things seem to be brighter, and I feel as if my manager wasn’t listening to her Cheshire Drive DS0000039939.V366107.R01.S.doc Version 5.2 Page 22 staff because of the workload, but I should comment that there has been a fast change.” The home has a quality assurance system and involves the service users as well as their families and friends in how the home is run and how the needs of the service users are met. The proprietors make regular monitoring visits to the home, and reports of their visits have been sent to the Commission. The AQAA provided evidence that there are good procedures for maintaining health and safety in the home. All the staff have training in moving and handling, fire safety, food hygiene and infection control as part of their induction. There is a monthly health and safety audit in the home. Health and safety records include regular checks of water temperatures, fire equipment and fire drills. Cheshire Drive DS0000039939.V366107.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 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 3 X Cheshire Drive DS0000039939.V366107.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA19 Regulation 15(1)(b) Requirement The manager must ensure that all care plans provide accurate and up to date details of each person’s needs, so that the staff have the information that they need to be able to meet their needs. Timescale for action 31/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cheshire Drive DS0000039939.V366107.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cheshire Drive DS0000039939.V366107.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. 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