Care Home: Consensa Care Ltd, 67 - 69 Highbury Gardens

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What the care home does well "It is a really positive home, management and staff are willing to go the extra mile for the resident", this was a comment received from a placement social worker. She has worked closely with staff following the placement of a resident two months earlier. Her findings so far are that staff are good at managing some complex situations that may be experienced in mental health as a result of drug and alcohol abuse. The current resident`s experience of living at the home is positive. The accommodation is excellent, with a comfortable and attractive environment provided. Routines are not too rigid but respond appropriately to changes that arise in individual conditions. The resident has experienced set backs on occasions but finds that staff keep him motivated to overcome some of the obstacles encountered. He said "If I am to progress I accept and appreciate the boundaries set out by the support worker and know that these are in my best interests". What has improved since the last inspection? This is the first inspection of this home. What the care home could do better: As this is the first inspection and there is only one resident a number of Standards could not be assessed. For the following areas requirements are set. The evidence was not available of staff training and development programme. The home needs to make sure that it has an appropriate training and development plan in place for the staff team so that they can gain the knowledge and expertise required for the complex needs of residents they plan to admit. The inspector will need to see a copy of this programme to evaluate it.Appropriate numbers of suitably skilled staff are available at the home, however it carries five vacancies. The staffing levels will need to be reviewed when the other residents move in. Staffing levels will need to be appropriate and reflect the numbers and needs of residents. CARE HOME ADULTS 18-65 Consensa Care Ltd, 67 - 69 Highbury Gardens 67-69 Highbury Gardens Ilford Essex IG3 8AF Lead Inspector Mary Magee Unannounced Inspection 27th September 2007 11:00 DS0000069071.V348695.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 DS0000069071.V348695.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. DS0000069071.V348695.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Consensa Care Ltd, 67 - 69 Highbury Gardens Address 67-69 Highbury Gardens Ilford Essex IG3 8AF 020 8551 0030 020 8551 2911 rks@consensacare.com 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) Consensa Care Ltd Renu Kumari Singh Care Home 6 Category(ies) of Past or present alcohol dependence (6), Past or registration, with number present drug dependence (6), Mental disorder, of places excluding learning disability or dementia (6) DS0000069071.V348695.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care (excluding nursing) and accommodation to service users of both sexes whose primary care needs on admission to the home are within the following categories:Service users with a mental disorder, excluding learning disability or dementia (Category MD) Service users with a drug dependency, past or present (Category D) 2. Service users with an alcohol dependency, past or present (Category A) The maximum number of service users who may be accommodated is 6 Date of last inspection Brief Description of the Service: This small care home is a newly operational care home. It is one of six homes owned by Consensa Care. It provides accommodation and support to six adults in the younger age group, whose primary needs relate to mental health conditions. The premises is a large semi detached house on a residential street in East London. It is close to public transport, the nearest rail link is Seven Kings over ground station. The home has six single bedrooms, all with en suites. The dining room is open plan with a large fully equipped kitchen area attached. On the ground floor is a furnished spacious lounge. Additional communal areas include a smoking lounge on the ground floor, also a small quiet area on the first floor. A bathroom is available on the ground floor, this is wheelchair accessible. Fees range from £1500 to £2500 per week DS0000069071.V348695.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over one day. It lasted over four hours. During this period the inspector met with the registered manager, all four staff members and the one resident currently living at the home. A selection of personnel records for support staff and the one resident were examined. A placement social worker spoke to the inspector of her experiences and the outcome of the current placement. What the service does well: What has improved since the last inspection? What they could do better: As this is the first inspection and there is only one resident a number of Standards could not be assessed. For the following areas requirements are set. The evidence was not available of staff training and development programme. The home needs to make sure that it has an appropriate training and development plan in place for the staff team so that they can gain the knowledge and expertise required for the complex needs of residents they plan to admit. The inspector will need to see a copy of this programme to evaluate it. DS0000069071.V348695.R01.S.doc Version 5.2 Page 6 Appropriate numbers of suitably skilled staff are available at the home, however it carries five vacancies. The staffing levels will need to be reviewed when the other residents move in. Staffing levels will need to be appropriate and reflect the numbers and needs of residents. 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. DS0000069071.V348695.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 DS0000069071.V348695.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 4 5 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home is making good preparation for people using the service to have all the necessary information before they move there. All receive the opportunity for trial visits and meet other residents to get feel of the home. The personal needs assessment means that any individual is not admitted unless the home is satisfied that it can meet the person’s needs. Contracts are agreed with residents. EVIDENCE: The inspector observed a copy of the Statement of Purpose, also seen a copy of the service user’s guide. According to the registered manager a copy of the guide is given to all new residents. As the service is relatively new only one resident has yet moved into the home. He has resided there for two months. He has found the experience so far satisfactory. He came to visit the home prior to admission, and said “I liked the feel of it immediately, it is homely and relaxed”. Another prospective resident has been visiting the home recently, as the current resident has been absent on both occasions another visit is arranged so that this individual can meet the resident. The registered manager feels that compatibility is important and plans to continue the process of introducing prospective residents for trial visits, this to enable them meet with residents and get a feel for the place, also to make sure that personalities are compatible. The resident recognises the support he needs to manage his DS0000069071.V348695.R01.S.doc Version 5.2 Page 9 conditions, he described the support so far from named staff as appropriate and how beneficial it is in reinforcing boundaries. The resident was issued with a contract, a copy of this and terms and conditions are held on the resident’s file. The current resident’s file was examined to evaluate the pre admission process also to check on the preparations through assessments. There is evidence of close working with mental health professionals and getting all the necessary information for prospective residents, this has helped decide if the home is suitable to meet the individual’s needs. There was good detail recorded on pre admission assessments, these include personal history with detail of conditions and treatments, also supplied were risks associated with the individual due to conditions, and risks to staff and other residents. A record was held of all prescribed medication. There was additional information supplied by mental health professionals that included the psychiatrist’s report. The resident is on an enhanced CPA. DS0000069071.V348695.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. Support plans and risk assessments are developed with residents that identify personal goals and objectives. These are reviewed on an ongoing basis and tailored to reflect changes in needs and circumstances. Residents may experience restrictions that are necessary to prevent self-harm or neglect as agreed in CPA or support plans, they receive the necessary support to take risks, make informed decisions about their lives. EVIDENCE: The home has one resident currently residing there as the service is new. The resident spent time with the inspector and shared his views of his experience of the service. He is aware of the restrictions imposed as he is on an enhanced CPA. A care plan is in place that covers all areas of personal and social care support as well as healthcare needs. The plans were developed and agreed following admission. Records show that these are reviewed and record all changes that arise. The home has completed comprehensive risk assessments. These highlight all areas of risk that is posed to the resident, also to staff and other residents. DS0000069071.V348695.R01.S.doc Version 5.2 Page 11 The home is constantly reviewing these risks identified and amending the assessments and support plans to reflect the changes. The resident is aware of the changes that arise in his condition and how his support needs are changing and his tendency to relapse. As he has been absent frequently from the home since his admission new support plans are under development that reflect where support may be more beneficial. Prior to the inspection a meeting took place with placement social worker and the registered manager. This was to discuss the resident’s progress and to also deal with the areas where setbacks were experienced. The inspector spoke to the placement social worker by telephone. Confirmation was received that the home is providing very well for the resident and managing to support him through some difficult periods. The inspector viewed the procedures for supporting the resident to manage his personal finances. As the resident needs support with managing finances more wisely staff provide support and tuition in this area. So far he is finding the procedures to be beneficial. The resident is receiving advocacy services. This is funded by the resident, an arrangement in place prior to admission. The registered manager is arranging to enable the resident access local advocacy services, (at no cost to the resident) DS0000069071.V348695.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): 12 13 14 15 16 17 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents take responsibility for undertaking tasks in the home as part of leading an independent lifestyle. Staff at the home provide residents with opportunities to engage in appropriate leisure and educational activities. EVIDENCE: The home is making provision for the current resident to engage in appropriate activities. The resident enjoys living at the home. He says “It is non institutionalised and homely”. Observations made were that he feels he can access and use all communal areas of the home freely. Encouraging his creative abilities has motivated him; he has involved himself and takes responsibility for designing and looking after the garden. The garden is very pleasant and reflects the attention that it has been given. These tasks and those of cooking and housekeeping duties make the resident feel valued and worthwhile. He has a keen interest in music and plays guitar. A member of staff had enquired about a music workshop in the community, an appointment was arranged for the resident to attend. Unfortunately due to set backs in his condition this was not kept. A support worker discussed this with the resident DS0000069071.V348695.R01.S.doc Version 5.2 Page 13 during the inspection. Following discussion he was in the process of rearranging a new appointment for him to attend. The resident draws up with a support worker a weekly programme of activities that he wishes to pursue. It was not possible to evaluate participation due to frequent absenteeism from the home. He told the inspector that he was becoming familiar with the area and community. Due to previous restrictions and agreements on support plans he accesses the community with a support worker escorting him, he frequents local shops and parks. The resident likes the flexibility afforded at the home. Routines are not rigid and he feels comfortable with how his privacy is respected. Staff do not enter his bedroom without been invited unless there are concerns for his welfare Staff are there to support, encourage and enable. The emphasis is on developing skills that aim towards independence and developing the necessary skills. Staff are good at supporting the resident through difficult periods, recognise relapses and setbacks and encouraging him to resume with activities that he enjoys. He told the inspector that he is not in contact with family at present, although they are aware of where he is living. He meets up with old friends on occasions. He chooses the food he likes and cooks it as part of his daily programme of living activities. The inspector noticed that staff purchased fresh fruit for the resident. This was to encourage him to eat healthily as he had been absent for a short period. They were aware that he had not had good nutrition during this period. Records were not available of meals consumed. A recommendation is made. Staff should ensure that records are maintained of all meals taken DS0000069071.V348695.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. The home has effective systems in place for meeting the physical and psychological health care needs of residents. Residents are prompted and encouraged to attend self-help groups that help them with addictions and dependency issues. EVIDENCE: The current resident does not require assistance with personal care. Staff however recognise that the individual may need prompting and encouragement. A local GP practice accepts new patients from the home. Generally the service experienced so far is good. Records seen demonstrate that the GP is consulted frequently on healthcare issues. The registered manager finds the GP to be helpful and supportive with the resident. While attending the surgery the resident is weighed and given advice about his health conditions. It is recommended that residents’ weights be monitored at the home. Staff has a system in place for the current resident to use the bedroom located beside the office on return from periods of absconding. This enables staff to manage risks, monitor his welfare (especially emotional needs) more closely. More encouragement is needed at this time with promoting personal hygiene, DS0000069071.V348695.R01.S.doc Version 5.2 Page 15 this staff do. Records are held of all observations made. All four staff spoken to are have a good awareness of appropriate actions to take in safeguarding oneself from health conditions that may be infectious. Protective clothing is also provided for this. Psychological needs are monitored on an ongoing basis. The resident attends support groups (AA) that meet in the community twice weekly Reports are made to relevant authorities if a resident absconds. There are also meetings held between staff and placement social workers to discuss the needs and the impact of frequent absconsions. The placement authority reported that staff at the home are pro active in encouraging and promoting the psychological well being of residents. The medication procedures for the resident were observed, also records to demonstrate compliance with medication. The current resident is not self medicating. A medication profile is in place recording all prescribed medication, also side effects. Medication is stored in a locked cabinet in the office. It is supplied in blister packs. MAR sheets are kept with signatures of staff available for all medication administered. There is no evidence to suggest that the resident is non compliant. There are numerous occasions where medication is left over as the resident has not been present for it to be administered. The registered manager should ensure that a safe system is in place for recording medication returned from the home. DS0000069071.V348695.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. Staff are knowledgeable on safeguarding vulnerable adults procedures. Residents are given information on the complaints procedure in place at the home. EVIDENCE: The home has experienced a resident frequently absconding. All the appropriate actions have been taken in response to this including relevant notifications. On return to the home staff are careful and make sure that the resident is closely observed for fist few days following return. The bedroom known as the breakout room is used to minimise risks any risks to residents or staff. Staff spoken to have a good awareness of safeguarding vulnerable adults and of the procedures to follow if there is suspicion of abuse or neglect. The inspector did not observe the training schedules proposed, this is referred to in training and development standard. No complaints have been received at the home since it commenced operation two months ago. A complaints format is supplied with the service user’s guide to residents. Observations made during the inspection were that the resident feels confident in openly expressing his views to the manager and staff. DS0000069071.V348695.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 30 Quality in this outcome area is excellent, This judgement has been made using available evidence including a visit to this service. The home offers a homely, clean, comfortable and safe environment that residents appreciate. Good quality individual accommodation as well as communal lounge and dining areas is complimented by attractive furniture and fittings. EVIDENCE: The home is newly operational. It is very attractive with furnishings and furniture well coordinated. The home is clean and hygienic. All the bedrooms and communal areas were toured. The six single bedrooms are spacious, attractively decorated and furnished. All bedrooms are en suited. All bedrooms have a new television supplied. On the ground floor is a well-furnished lounge, a dining room/kitchen. Also on the ground floor is a toilet and shower facilities that is accessible to wheelchair users. An additional small lounge quite area is provided on the first floor. All areas are smoke free except for the smoking room available on the ground floor. DS0000069071.V348695.R01.S.doc Version 5.2 Page 18 The garden to the rear is a good size band provides a pleasant area for resident to enjoy outdoors. The current resident was complimentary on the presentation, he said, “It is a lovely house and it feels homely and comfortable”. DS0000069071.V348695.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 34 35 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The recruitment procedures for those currently working at the home are thorough. Although the majority of the support staff engaged are experienced staff they are permanently engaged from an agency. The home has plans to recruit them permanently on the staff team. Copy of the training and development programme is needed to determine if appropriate provision is made to train and develop the staff team EVIDENCE: The inspector met all four support workers currently employed. One is directly employed by the organisation. The remaining three staff are engaged via an agency and have worked there since it opened in July 2007. Plans are underway to recruit all three members of staff to the team permanently, application forms have been completed by the three agency staff. For the in house member of staff appropriate documentation was available to confirm that vetting procedures had been thorough. For the remaining three agency staff documentation was supplied by the agency including CRB with enhanced disclosures. All members of staff met with the inspector. A routine staff meeting scheduled for the afternoon took place. Individually support staff (four) told of their previous work experience and demonstrated a good knowledge of supporting people with mental health related conditions. DS0000069071.V348695.R01.S.doc Version 5.2 Page 20 Staff have regular staff meetings, some said they receive supervision. Records of supervision were not present to evidence this. A recommendation is made regarding supervision. The current staff engaged have previous experience of working with people with mental health related conditions; evidence was available on staff files too of this. There were some certificate present on staff files to confirm that staff received training prior to placement such as NVQ and understanding and managing challenging behaviour, mental health training, medication training, POVA training. The in house staff member confirmed that he had received induction training, he is also completing NVQ programme that he began in previous employment. Evidence was not available on the staff file to confirm the induction, neither was there a copy of Skills for care Induction programme this. The registered manager confirmed that the organisation has a corporate plan to develop and train the staff team so that they have the necessary skills and knowledge to meet the needs of residents. It was not available for evaluation. A requirement is stated in relation to the provision of a training and development programme for staff. The shift pattern was examined. There is always one member of staff on duty during daytime hours; also present is one waking night staff. This may be appropriate for current resident. However the registered manager needs to review staffing levels as more resident s move into the home. The staffing levels will need to reflect and be appropriate to the needs and numbers of residents. A requirement is stated in relation to staffing levels. CSCI must be kept informed in writing of the staffing arrangements as additional residents move to the home. Staffing levels must be appropriate to the assessed needs and number of residents. DS0000069071.V348695.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 41 42 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. It was not possible to evaluate Standard 39 in this short period of operation. Residents benefit from living in a home that is well run by a manager that is experienced and that is interested in the residents’ welfare. The health and safety of residents and staff is safeguarded and promoted by policies and procedures that promote safe working practices. EVIDENCE: The home has been operating for two months. There are formats in place for self-auditing and self-monitoring that contribute to quality assurance process. However as the service has been operating for just two months it was not possible to evaluate the quality assurance process. The registered manager is experienced and enthusiastic. She displays a keen interest in the welfare of the resident. Her relationship with the resident is good, this was observed as both she and the resident spent time discussing DS0000069071.V348695.R01.S.doc Version 5.2 Page 22 future plans for activities programme. The resident feels safe, he is confident in her ability to provide a home that is well run and that focuses on the welfare of residents. The registered manager is qualified. A social worker spoken to finds that the manager is reliable and patient, she is keen to work with residents and support them overcome obstacles and setbacks. She described recent events at the home when the resident absconded, she said, “the manager had gone all over the place looking for the resident and did everything possible to help”. As well as current post she is responsible individual for six homes, is also covering some management duties in another home in the absence of the regular manager. She spoke of her plans to step down soon as registered manager and to recruit a new manager for the home. A recommendation is made that the registered person should keep CSCI informed on when she plans to resign and the progress made in recruiting a new manager. The premises are safely maintained, current records of gas and electrical certificates were seen. Also present was confirmation that a fire emergency plan is in place, weekly testing of fire alarms, agreement for servicing of fire fighting equipment. Temperatures of fridge and freezers are checked daily, hot water supplies are monitored and recorded. Health and safety issues are discussed with staff. Appropriate arrangements are in place to safeguard staff and other residents to identify and manage appropriately any risks identified and associated with challenging needs. Record keeping is good. Both staff and current resident’s file are well organised with all essential information documented with correct dates and accurate. Appropriate notifications are made to relevant bodies of any notifiable incidents. DS0000069071.V348695.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 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 4 25 4 26 4 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X X X 3 3 X DS0000069071.V348695.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 YA32 YA35 Regulation 18 (1) c Requirement The registered person must supply the CSCI with a copy of the training and development programme planned for staff so that this can be evaluated. Also to be supplied is a copy of the structured induction programme that meets Skills for care workforce targets. The registered manager must ensure that staffing levels are reviewed when additional residents move to the home, staffing levels must reflect and be appropriate to the needs and numbers of residents. A copy of the outcome of this review to be forwarded to the CSCI. Timescale for action 30/10/07 2 YA33 18 (1) a 30/10/07 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 DS0000069071.V348695.R01.S.doc Version 5.2 Page 25 1 2 3 4 3 YA17 YA17 YA20 YA36 YA37 The registered person should ensure that records are maintained of all food consumed by residents. The registered person should ensure that a record is held of food consumed by residents. The registered person should ensure that a safe system is in place for disposal/return of medication from the home. The registered person should ensure that records are maintained of all supervision sessions held. The registered person should ensure that CSCI is kept informed on management arrangements, that is when the registered manager resigns and the management arrangements in place to lead the home. DS0000069071.V348695.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 DS0000069071.V348695.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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