Care Home: Davids Close (2)

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What the care home does well This is a good service which mostly meets the needs of the people who live here. The manager has developed her confidence and under her leadership the home has come a long way. These are some of the responses we received from our survey: "I like where I live and I like the staff"; "At the moment my relative seems a lot happier there so things must be improving"; "I have always found the atmosphere to be relaxed and friendly....it is always clean and tidy and the food is good"; "My relative is well cared for and I have no complaints"; "My relative is happy and settled at 2 David`s Close. I think very highly of the staff and the standard of care provided"; "The atmosphere within the home is relaxed and comfortable, whilst at the same time staff are thoroughly professional". Most of the people who live at 2 David`s Close attend day services. We were pleased that the manager asked the staff at the day services to help people complete the survey we sent out. Two surveys were returned to us with an accompanying letter, stating that although the people from the home had been unable to answer the questions, observation showed that "their personal hygiene is good, they appear well-fed and dressed appropriately. They appear to be happy in the company of the staff and always appear to be happy to go home with them". What has improved since the last inspection? We were very pleased to note that ten of the eleven requirements made at the last inspection had been met, and the other one had been partly met. The look of the house, both inside and out, has improved enormously. For the first time in the years we have inspected this home, 2 David`s Close looks like a house that is really cared for. We noted at our last inspection that improvements had started to be made: since then, all the new building work, a lot more decorating of the inside of the house, tidying up of the grounds and gardens, and so on has all come together and the home looks really good. Almost the whole of the inside of the house has been decorated, including the hall, lounge and several bedrooms. More importantly, homely touches, such as side tables, lamps and pictures in the lounge, have been added to make the house a comfortable home. Each person has had the opportunity to choose colours and furnishings for their bedroom, and to add their own choice of personal belongings. Thermostatic valves have been installed so hot water comes out of the taps and showers at a safe temperature, the home smells pleasant, and we did not see any chemicals not stored safely. Care plans have improved and contain good, clear, detailed information about people`s abilities and the support they need from the staff. The range of opportunities for leisure activities has improved, and people have developed their living skills. Staff have received training in fire safety awareness twice since the last inspection, and tests of the fire alarm, emergency lights and fire equipment have taken place regularly as required. What the care home could do better: Several people who responded to our survey said that more staff are needed, and that sometimes people`s opportunities are limited because there are not enough staff on duty. The manager has been working hard to obtain increased funding for the people who live at 2 David`s Close so that sufficient staff can be employed to meet people`s needs. She is still working on this, and has employed more staff so that the people who live here can do specific activities. However, there are still times when staffing is not adequate to meet everyone`s needs, and this must continue to be improved on. Medicines must be stored properly. CARE HOME ADULTS 18-65 Davids Close (2) Werrington Peterborough PE4 5AN Lead Inspector Nicky Hone Unannounced Inspection 3rd December 2007 09:00 Davids Close (2) DS0000015147.V356040.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 Davids Close (2) DS0000015147.V356040.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. Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Davids Close (2) Address Werrington Peterborough PE4 5AN 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) 01733 707774 F/P 01733 707774 Mr Alan George Atchison Mrs Tracie Ann Green Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2006 Brief Description of the Service: Originally a large, detached private house, set in its own grounds, 2 David’s Close became a home for people with learning disabilities in 1995. There are two single bedrooms, a shower room, two lounges, dining room, kitchen and laundry on the ground floor, as well as an office/sleeping-in room and staff shower room. On the first floor there are five single bedrooms and a bathroom. One bedroom upstairs and one bedroom downstairs have an ensuite shower room. The gardens include a wooded area along the rear fence and there is a fully enclosed outdoor swimming pool, which is no longer used. Located in a quiet cul-de-sac on the outskirts of Werrington, the home is within a ten-minute walk of local amenities, and is three miles from the centre of the cathedral city of Peterborough with its wide range of shops and leisure facilities. Planning permission has been granted by Peterborough City Council for an extension to the rear of the house which would increase the number of bedrooms. The provider has decided not to start this work yet. The fees for the places at 2 David’s Close are around £800 per week, depending on the support needed by each individual. Inspection reports are available on request from the manager. Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. For this inspection we (the Commission for Social Care Inspection) looked at all the information that we have received, or asked for, since the last key inspection of 2 David’s Close. This included: • The AQAA (Annual Quality Assurance Assessment) that the manager completed and sent to us in September 2007. The AQAA is a selfassessment that focuses on how well outcomes are being met for people living at the home. It gives the manager the opportunity to say what the home is doing to meet the standards and regulations, and how the home can improve to make life even better for the people who live there. The AQAA also gives us some numerical information about the service; Surveys which we sent to people who live at 2 David’s Close, to their relatives/carers, and to staff. We received a total of seventeen replies. Some of the comments from the surveys are quoted in the summary and in the body of the report; What the service has told us about things that have happened at the home, these are called ‘notifications’ and are a legal requirement; and Reports sent to us by the provider following monthly visits they make to the home. • • • This inspection of 2 David’s Close also included an unannounced visit to the home on 03/12/07. During our visit we spoke with people who live at the home, staff and the manager, and looked at some of the paperwork the home has to keep. This included assessments, care plans, medication charts, and records such as staff personnel files, rotas, and fire alarm test records. We looked round the house. What the service does well: This is a good service which mostly meets the needs of the people who live here. The manager has developed her confidence and under her leadership the home has come a long way. These are some of the responses we received from our survey: “I like where I live and I like the staff”; “At the moment my relative seems a lot happier there so things must be improving”; Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 6 “I have always found the atmosphere to be relaxed and friendly….it is always clean and tidy and the food is good”; “My relative is well cared for and I have no complaints”; “My relative is happy and settled at 2 David’s Close. I think very highly of the staff and the standard of care provided”; “The atmosphere within the home is relaxed and comfortable, whilst at the same time staff are thoroughly professional”. Most of the people who live at 2 David’s Close attend day services. We were pleased that the manager asked the staff at the day services to help people complete the survey we sent out. Two surveys were returned to us with an accompanying letter, stating that although the people from the home had been unable to answer the questions, observation showed that “their personal hygiene is good, they appear well-fed and dressed appropriately. They appear to be happy in the company of the staff and always appear to be happy to go home with them”. What has improved since the last inspection? We were very pleased to note that ten of the eleven requirements made at the last inspection had been met, and the other one had been partly met. The look of the house, both inside and out, has improved enormously. For the first time in the years we have inspected this home, 2 David’s Close looks like a house that is really cared for. We noted at our last inspection that improvements had started to be made: since then, all the new building work, a lot more decorating of the inside of the house, tidying up of the grounds and gardens, and so on has all come together and the home looks really good. Almost the whole of the inside of the house has been decorated, including the hall, lounge and several bedrooms. More importantly, homely touches, such as side tables, lamps and pictures in the lounge, have been added to make the house a comfortable home. Each person has had the opportunity to choose colours and furnishings for their bedroom, and to add their own choice of personal belongings. Thermostatic valves have been installed so hot water comes out of the taps and showers at a safe temperature, the home smells pleasant, and we did not see any chemicals not stored safely. Care plans have improved and contain good, clear, detailed information about people’s abilities and the support they need from the staff. The range of opportunities for leisure activities has improved, and people have developed their living skills. Staff have received training in fire safety awareness twice since the last inspection, and tests of the fire alarm, emergency lights and fire equipment have taken place regularly as required. Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 7 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. Davids Close (2) DS0000015147.V356040.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 Davids Close (2) DS0000015147.V356040.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, 4, 5 People who use this service experience good quality outcomes in this area. Good information about the home is available, and new people know the staff will gather information about them so that their needs will be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection the home has updated the service user guide, which is now produced in three different formats. As well as the written guide, there is one which also includes pictures and symbols, and the guide has been produced on CD-Rom. This means that information about the home is available to a wider group of people. One person has been admitted to the home in the last few months. Because of the person’s situation, the admission to 2 David’s Close was quite rushed. However, the staff team did their best to make sure they followed their admissions procedure as far as they could. The only assessment available from social services about this person was completed in 2005, so the home also asked for copies of the care plan that had been produced by the respite care home, to give the staff at 2 David’s Close as Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 10 much information as possible. Staff visited the person at the respite home, then she visited 2 David’s Close for tea and stayed for the evening. The manager spent a day with the person at their day service to get to know her, and so that the manager could do her own assessment. Although the admission was rushed, it is a credit to the staff team that the person appears to be settling into their new home well. Each resident has a contract with the home which is updated each year: we saw this on the file we looked at. Davids Close (2) DS0000015147.V356040.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 People who use this service experience good quality outcomes in this area. Care plans have improved so that there is clear guidance for staff on how each person wants to be supported. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During the inspection we looked at the care plans for two people, one of which was the new resident referred to in the Choice of Home section of this report. For the new person, staff used copies of the care plan built up by the respite home to give them a starting point, as little up to date information about this person was available. When we looked at the care plan we saw that since her arrival at 2 David’s Close, some clear guidelines about the support this person needs had been developed. We could also see that staff are gradually building up the care plan for this person as they get to know what she can do and what Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 12 she needs support with. Staff were closely monitoring and re-assessing her abilities and needs, and working with her to support her to make decisions about the way she wants to lead her life. The care plan for the second resident contained good, clear, detailed information about this person’s abilities and the support she needs from the staff. This person’s needs have been changing over the past few months, and several reviews have been held with her care manager. The care plan had been revised to reflect the changes discussed during the reviews. Risk assessments had been completed to support this person to take acceptable risks in her life. Davids Close (2) DS0000015147.V356040.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): 11, 12, 13, 14, 15, 16, 17 People who use this service experience good quality outcomes in this area. People who live at 2 David’s Close have a range of opportunities to live full and satisfying lives. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: On the wall in the entrance to the dining room each person has a board with their photograph on it: on the board is a weekly activity plan, with symbols to show more clearly what the activity is. A ‘daily activity chart’ is completed by staff four times a day so that a picture of each person and their life is shown clearly. One of the care plans we looked at showed that staff have worked hard to make sure this person leads a busy, satisfying life. A separate activity record Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 14 on the person’s file showed that she had lots of opportunities to undertake a range of activities. Each person also has ‘tasks’ agreed with them, which are things they want to learn to do better, for example, making a sandwich for their packed lunch. A daily task record gives details about the task the person is doing, and their progress is evaluated. New tasks are started every few weeks, but the person is encouraged to continue to undertake the previous tasks they have done, so they do not lose those skills. All six people who were living at the home in the summer had a holiday. Staff brought in lots of brochures and each person chose where they wanted to go. Two people chose to go to Great Yarmouth, two to Yorkshire, and two people went, separately, to Hunstanton. Before Christmas, each person was having a day out of their choice. For example, two people had chosen to go for a ride on the Nene Valley railway. At the time of the inspection, the owner was buying two cars for the home, in place of the big mini-bus, so that smaller groups of people can go to different places. She said that if everyone wants to go to the same place, then two cars could be driven. Everyone who lives at the home has a say in what is on the weekly menu, and people who want to help staff to do the shopping. All those who replied to our survey indicated that they are happy with the food. One relative wrote “the food is so good I wish they’d ask me to stay for dinner!” The manager said relatives are welcome to stay for dinner if they want to. Davids Close (2) DS0000015147.V356040.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 People who use this service experience good quality outcomes in this area. Medication is administered safely and people’s health is monitored so that they keep as well as possible. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We looked at one care plan belonging to one of the people who has lived at 2 David’s Close for some years. The plan showed that this person’s healthcare needs are met. We saw that she visits the doctor, dentist, optician, chiropodist and so on, when needed, and her weight is monitored. During the summer this person had become unwell so her mental health had been closely monitored by the home in liaison with professionals from the Learning Disability Team (Primary Care Trust). This person had given written consent for the staff at 2 David’s Close to administer her medication. We checked the MAR (Medication Administration Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 16 Record) charts and these had been correctly completed. The file we looked at contained good guidance for staff on administering ‘when necessary’ (prn) medicine, and any administrations of these were explained on the reverse of the MAR charts. The file also contained the information from the packet about each drug the person is taking. Medicines are stored in the office in a lockable filing cabinet. The CSCI pharmacy inspector had told the home at a previous inspection some time ago that this method of storage is not satisfactory. The manager (who was not in post at that time and was not aware the current system is not acceptable) said she would deal with this. We have made a requirement so that this matter is not forgotten again. Davids Close (2) DS0000015147.V356040.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 People who use this service experience good quality outcomes in this area. People know their views will be listened to and that staff know how to keep them safe. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The complaints procedure has bee produced in picture/symbol format for the people who live here, and was displayed on the notice board. People who replied to our survey were confident that they would know who to speak to if they had any concerns, and that their concerns would be dealt with. The manager said that all staff have undergone training in Protection of Vulnerable Adults (POVA – now known as Safeguarding Adults), either in 2006 or 2007. From issues that arose during the summer of 2007 it is clear that all staff at 2 David’s Close are aware of the correct procedures for reporting any matters under POVA. Each person who lives at 2 David’s Close keeps a small amount of money in a cash tin in the safe. Staff assist people to take out the money they need, and keep good records of what goes in and out. The manager audits the records weekly. We checked the records and cash for two people and they were accurate. Each person has an account with the City Council and staff can get larger sums of money from there whenever the person needs it. Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 30 People who use this service experience excellent quality outcomes in this area. 2 David’s Close gives the people who live there a safe, comfortable and clean home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A lot of work has been done at 2 David’s Close to make the house more of a home for the people who live here. Almost all areas of the home have been decorated during the past year. A number of homely touches, such as lamps, pictures, cushions and so on have been added to the lounge, and each person’s bedroom is decorated in colours and furnishings that they have chosen. Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 19 The manager told us that valves have recently been put on all hot water outlets, so the hot water comes out of the tap at a safe temperature. The downstairs shower has been replaced with one which controls the temperature, so some of the people who live at the home can now use the shower without staff having to monitor the temperature. The shower room in the ensuite in the newest bedroom has been fully tiled, and a washable floor has been put in the other ensuite, and in half of the bedroom. The gardens were well kept for the time of year, and the driveway and front of the house were neat and tidy. The manager told us that a gardener is now employed: he works on the gardens one or two days a week, depending on how much work there is to do. Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 People who use this service experience adequate quality outcomes in this area. Staff are well recruited, well trained and well supported, but there are not always enough staff on duty for people who live at the home to be able to do what they would like to do. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: One of the people who live at 2 David’s Close has the daily task of finding out which staff are on the rota, and putting their photograph in the appropriate slot on a board in the dining room. This helps everyone to know who will be coming on duty. We discussed the surveys that had been completed by the people who live at the home, their relatives and staff. Generally, the surveys were very positive, but one of the themes which was mentioned several times was that more staff are needed so that people can do more individual activities. Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 21 The manager told us that there are now three staff on duty on certain evenings in the week when specific activities take place. For example on Wednesday evenings when Breakaway Club is on, so that people can go if they want to. There are now three staff all day on Friday when several people are at home. In the New Year the manager hopes there will be three staff every Saturday and Sunday, from 10 a.m. to 6 p.m. so that the people who live at the home can get out more. From the responses to the surveys, most staff seem happy working at 2 David’s Close. One person wrote “Really nice place to work. Support staff really good team”; and another “We work as a team, there are no issues”. One of the completed staff surveys caused us some concern. The person appeared to have a different view of care and support of people with learning disabilities than the ethos the home now promotes. This was discussed, anonymously, with the manager, who will try to deal with the issue. All homes have to gather information about new employees before they start work at the home. We looked at the personnel file of a new staff member: all the required information, including satisfactory written references, a Criminal Records Bureau check, proof of identity and so on was on the file. There was no information about one person on the rota. This person also works at the owner’s other home, and all the information is there: we explained to the manager that copies of that information must also be at 2 David’s Close as it is her responsibility to ensure this person is suitable to be working here. Staff have had opportunities to do a number of training courses. We saw one staff member’s record which showed that in the last year they had done training in moving and handling; rectal diazepam; food safety; nutrition; bereavement; fire safety (plus a refresher); first aid; and Protection of Vulnerable Adults. The manager said all staff had done fire safety in May 2007, and undertaken a refresher in November 2007, and that she has done a four-day course on risk assessing. One of the staff has qualified as a Communication Coordinator, and a second staff member is booked to do this training in January 2008. From the records we looked at we saw that all staff have received regular supervision. Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 People who use this service experience good quality outcomes in this area. This home is managed well so that the people who live here are offered a good quality of life. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: From all the evidence we gathered, including discussion and observation, it is clear that the manager has developed in confidence during the past year and the home has come a long way under her leadership. The staff team has also developed and, on the whole, all are keen to continue to support the people who live at the home to improve their independent living skills and to lead full and satisfying lives. Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 23 A quality assurance system, based on the views of service users, relatives and other people involved with the home, is still being developed. Survey forms have been sent out and the responses collated. House meetings are held regularly, with each person being encouraged to join in and put their ideas forward. The owner carries out a monthly unannounced visit, (as required by Regulation 26, Care Homes regulations 2001) and writes a report. These reports were available in the office. We looked at the record of tests of the fire alarm and emergency lighting systems and noted that the tests have been carried out as required. The fire risk assessment had been reviewed, and fire extinguishers are checked monthly by the staff and serviced annually. Fire drills are held, and the building evacuated, at least quarterly. The cupboard in the laundry room was locked, and we did not see any chemicals that were not stored safely. Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 3 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 X 27 X 28 4 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 X 3 X X 3 X Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Medication must be stored securely. The lockable filing cabinet must be replaced with more secure storage for the medication. The registered person must ensure that an adequate number of staff is employed to meet the needs of the service users. Timescale for action 31/01/08 2. YA33 18(1)(a) 31/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Inspection 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 Davids Close (2) DS0000015147.V356040.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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