Care Home: Dimensions 49 Chichester Court

Similar services:

• Wadham Avenue
• Chatsworth Care - Dawson House
• Cowden Road, 52 - 54
• Chatsworth Care - Tudor Lodge
• Foxley Lane (121a)
• Ashlong House
• Norbury Crescent (30)
• Edenvale

What the care home does well The home is undertaking good consultation processes and people using the service, staff and stakeholders are involved in the forward planning of the home and organisation. The manager has a wide range of experience and is qualified to manage the home. Health and Safety monitoring is done regularly and a safe environment is provided for people using the service. Staff interviewed provided good feedback about the training and support received from the manager. Recruitment processes are robust and staff are vetted to ensure people using the service are protected from unsuitable staff. The home is supporting staff to undertake National Vocational Qualification in Care and over 60% of staff hold these or similar qualifications. The home has undergone a complete refurbishment and the upstairs area is now self-contained, this allows the home to match and support residents according to the ability and needs. New prospective residents are encouraged to test drive the home and appropriate information is provided to purchaser and people using the service. What has improved since the last inspection? The home has met all twenty requirements, which have been made following the key inspection in May 2008.The home has updated the statement of prospective residents are provided with the necessary information about the home. Care plans are reviewed regularly and people using the service, relatives and significant others are involved in the review process. The independent finance audit has been completed and recommendations have been actioned. The home has robust risk assessment procedures in place. The home is supporting people using the service in accessing community-based activities. Residents are involved in the menu planning, shopping and cooking. Staff has supported residents to access health and remedial services. All staff has attended communication training. A chiropodist has seen residents and regular follow up appointments are arranged. The home has obtained a list of peoples allergies from their GP. Staff have attended medication training and a signatory list is in place. Medication is safely stored in metal lockable medication cupboards. Staff attends Safeguarding Adults training and an ongoing training programme is provided. Staff has attended challenging behaviour training and are confident in supporting people living at the home. What the care home could do better: We have made no requirements during this inspection. CARE HOME ADULTS 18-65 Adepta 49 Chichester Court 49 Chichester Court Stanmore Middlesex HA7 1DX Lead Inspector Andreas Schwarz Key Unannounced Inspection 29th October 2008 09:00 Adepta 49 Chichester Court DS0000062735.V372951.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 Adepta 49 Chichester Court DS0000062735.V372951.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. Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Adepta 49 Chichester Court Address 49 Chichester Court Stanmore Middlesex HA7 1DX 020 8905 0068 020 8343 8876 cbeard@adepta.org.uk www.pentahact.org.uk PentaHact Ltd trading as Adepta 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) Christopher William Beard Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th May 2008 Brief Description of the Service: 49 Chichester Court is the largest of four houses in a purpose-built complex previously managed by Hillstream Care but now by Adepta (formerly known as PentaHact) following a merger during the late summer of 2004. In August 2008 Adepta has merged with Dimensions. Metropolitan Housing Association maintains the building. The home provides long-term care and accommodation for up to seven adults with learning, physical and sensory disabilities. There were two vacancies at the time of the inspection. All people using the service have their own bedrooms. The home has been completely refurbished since the last key inspection. Bedrooms are on the ground and first floors. There is a spacious lounge, two dining areas, and a large garden to the rear. The ground floor is fully wheelchair accessible. Access to the first floor is by stairs only. The home is close to shops, leisure facilities and local transport. It shares a minibus with three homes in the same complex. Unrestricted parking is available on the road leading to the house. Fees and charges can be obtained from the Homes Manager or Operational Manager. Adepta 49 Chichester Court DS0000062735.V372951.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 stars. This means the people who use this service experience good quality outcomes. This key inspection took place in October 2008 and lasted 5 ½ hours. The registered manager and deputy manager were available for parts of this inspection. We spoke to two members of staff during this inspection. We observed staff interacting with residents and assessed two care plans, and other documents relevant making an assessment about the quality of care provided by the home. The home returned an improvement plan following the last key inspection. We would like to thank everybody involved in the key inspection process and providing the Commission for Social Care Inspection with information. What the service does well: What has improved since the last inspection? The home has met all twenty requirements, which have been made following the key inspection in May 2008.The home has updated the statement of prospective residents are provided with the necessary information about the home. Care plans are reviewed regularly and people using the service, relatives and significant others are involved in the review process. The independent finance audit has been completed and recommendations have Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 6 been actioned. The home has robust risk assessment procedures in place. The home is supporting people using the service in accessing community-based activities. Residents are involved in the menu planning, shopping and cooking. Staff has supported residents to access health and remedial services. All staff has attended communication training. A chiropodist has seen residents and regular follow up appointments are arranged. The home has obtained a list of peoples allergies from their GP. Staff have attended medication training and a signatory list is in place. Medication is safely stored in metal lockable medication cupboards. Staff attends Safeguarding Adults training and an ongoing training programme is provided. Staff has attended challenging behaviour training and are confident in supporting people living at the home. 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. Adepta 49 Chichester Court DS0000062735.V372951.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 Adepta 49 Chichester Court DS0000062735.V372951.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): We assessed National Minimum Standards 1 and 2 during this unannounced key inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. New prospective people using the service receive detailed information about the home, prior to being assessed appropriately, to establish if the home is able to meet their needs. EVIDENCE: The home has updated their statement of purpose and a copy has been forwarded to the Commission for Social Care Inspection. The statement of purpose is compliant with National Minimum Standards. The home has an admissions procedure and policy in place. The procedure states that new prospective people using the service are able to test-drive the home. Assessments of people living at Chichester Court are archived. The funding authority has assessed all residents living in Chichester Court using the fair pricing tool. We viewed these assessments during this key inspection. The information provided in these assessments addresses the support residents Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 9 need on a daily basis in Chichester Court, it gives no information of how the support is provided. Adepta 49 Chichester Court DS0000062735.V372951.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): We assessed National Minimum Standards 6, 7 and 9 during this unannounced key inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service understands the right of individuals to take control of their lives and to make their own decisions and choices. There is evidence that individuals are involved in decision-making about the home, such as day to day living and social activities. Each individual has a care plan, which is reviewed involving the service user. Risk assessments are completed and are of good standard. EVIDENCE: We assessed two care plans during this key inspection. Care plans are of good standard and quality. The home has introduced a new care-planning format and care plans have been updated. Care plans have been reviewed, we viewed minutes in all care plan folders. Care plans are holistic and address health, community living, behaviour, personal care, domestic duties, money, Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 11 communication and leisure facilities. The resident’s family and his circle of support is involved Person Centred Planning process and records have been signed. All care plans have been reviewed internally by key worker, resident and family, and externally by the placing authority involving the above. Key workers meet with residents monthly and a monthly report is produced. We observed staff interacting and supporting people using the service appropriately. The home has access to an advocacy project in Hertfordshire and some residents have an advocate allocated while other residents are currently on the waiting list. The home tried to obtain advocacy from Brent Advocacy Concern, but had great difficulties with this due to the long waiting list of this service. The placing authority has audited resident’s accounts and found some irregularities. Following this a safeguarding adults strategy meeting was arranged and one of the actions was, that all accounts are independently audited. The home has completed the external financial audit as required previously and recommendations made have been actioned. We viewed a detailed action plan produced by the operation Manager. We observed handover, resident’s finances are checked at each handover; the home is using special bags to keep the money, which are sealed. Staff explained to us that they only count the money if the seal is broken. We observed staff giving money to residents before leaving the home. Staff explained that due the level of residents ability they are not able to self manage their finances. The registered manager has reviewed risk assessments since the last inspection. Risk assessments are of great detail and provide staff with a detailed action plan to minimise risks. Risk assessments are detailed and address issues such as absconding, swallowing difficulties, moving and handling, etc. The home has a detailed Health and Safety risk and fire risk assessment in place. We viewed detailed challenging behaviour guidelines for people using the service, one of the reactive actions to minimise challenging behaviour in these guidelines is the use of “Proactive Strategies for Crisis Intervention and Prevention” (SCIP). Adepta 49 Chichester Court DS0000062735.V372951.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): We assessed National Minimum Standards 12, 13, 15, 16 and 17 during this key inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunity to develop and maintain important personal and family relationships. Residents are involved in the domestic routines of the home and take responsibility for their own room, menu planning and cooking meals with the help of staff. Residents are supported to access community based activities. EVIDENCE: Four residents living at the home go to Strathcona daycentre in Harrow and one person is going to Albert Road day centre in Queenspark. The home is providing day service for one of the people living at 49 Chichester Court. We observed residents leaving the home with a support worker to do some Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 13 personal shopping. Part of the care plan is looking at developing domestic skills and detailed guidelines are in place. The home is providing in house and community based day service for one of the people living at Chichester Court. The manager and staff informed us that daily activities and participation is recorded in daily records. Records show that the person is offered regular activities. The home looked into going swimming, the persons GP, due to health risks, has discouraged this. Application forms and other information relating to activities are on file. The home has access to transport, which is shared with two other schemes. The home has three staff on shift during the morning and three staff on shift during the afternoon and during weekends. We noted in one care plan that the home is supporting the person to go to church every Sunday. The home told us in the improvement plan that two residents access places of worship of their choice with staff support. The home is addressing relationships and sexuality within the care planning process and residents are encouraged to maintain relationships with families. The home has done a lot of work to establish relationships with family members and two residents have increased contact with their family. The home has a relationship policy in place. Families and representatives are regularly invited to parties and are involved within the quality assurance process. Residents have the opportunity to meet non-disabled people in pubs, café’s, and community based activities. The manager informed us that the home has met with parents and significant others, to discuss the planned change of service to domiciliary care. Staff were observed supporting residents with respect. One of the residents at the home is provided one to one support, which was observed during this key inspection. We observed residents move around freely and the ground floor of the home is fully wheel chair accessible. Residents are encouraged to take part in household activities and staff told us that residents who are not able to clean their room are encouraged to be present when staff do the weekly cleaning. Each day a different person is encouraged to take part in cooking of the main meal. Staff informed us that meals are discussed at the weekly residents meeting using a pictorial menu book allowing residents to make a choice. A picture of the daily meal was displayed on the notice board in the kitchen. The home has re introduced a weekly menu. Meals provided are healthy, nutritious and culturally appropriate. Staff is supporting residents to do their shopping daily and choose what they want to have. One of the residents is cooking for the other people living at the home. The home is recording food consumed by residents in their daily logbook. Fruit and drinks were available during this key inspection. Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 14 Adepta 49 Chichester Court DS0000062735.V372951.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): We assessed National Minimum Standards 18, 19 and 20 during this key inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service are supported and provided with and around health care appointments. There are no gaps in the medication administration and guidance protects people using the service. EVIDENCE: We viewed detailed personal care guidelines in care plans assessed during this key inspection. The guidance provides staff with information in areas people require support and areas they can do independently. Residents clothes were gender appropriate and staff told us that they support residents in purchasing new clothes. Staff told us that during weekends residents get up later unless they have anything arranged. The home has fitted ceiling hoists in the bathroom and in two bedrooms, which is used by residents with mobility problems. We viewed detailed risk assessments in how to use these hoist safely. Staff told us that since fitting the ceiling hoists it is much easier to Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 16 support people around their personal care. The home is referring people with the help of the local GP to access physiotherapy. Staff told us that this has been difficult and is still ongoing for one of the residents living at Chichester Court. This was confirmed by correspondence viewed during this key inspection. Speech and language therapy has been involved and recommended for staff to attend a two days communication course. Staff and records confirmed that staff has attended such training. In care plan files we found records of people using the service meeting health care professionals such as General Practitioner, dentist, dietician, psychologist, psychiatrist, etc. Records do document the outcomes of these visits and if there are any follow up appointments necessary. Previous inspections addressed the need for regular chiropodist appointments, a chiropodist has seen residents since the last inspection and regular chiropodist appointments are arranged for service users. The home is using Monitored Dosage System supplied by Boots. We viewed two Medication Administration Sheets during this inspection and all records were complete and had no gaps. Some residents receive liquid medication; one of the bottles has not been dated when opened. This has been discussed with the manager, who told us that he has discussed this with staff following the last inspection. The home contacted the local GP to obtain a list of peoples allergies. Staff competent in the medication administration has signed a signatory list. Training records show that staff has attended medication training. One of the people living at the home is self-administering insulin, a risk assessment is in place and consent was obtained from the person’s relative. The home is monitoring the medicines fridge temperature daily. Adepta 49 Chichester Court DS0000062735.V372951.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): We looked at all the above standards during this key inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows residents to express their views and concerns The service has a complaints procedure that is clearly written and easy to understand. Staff has received Safeguarding Adults training and have awareness of abuse and its many forms. The policies and procedures for safeguarding adults are available to staff. EVIDENCE: The home has a complaints policy in place, which is available in pictorial form. The manager told us, that the home has received one complaint since the last key inspection; this complaint has been resolved. Staff spoken to informed us that they would inform the manager if someone were complaining to them. The home has a complaints log to record complaints. Staff spoken to confirmed that they have taken part in Safeguarding Adults training. The manager and training records confirmed that staff have attended Safeguarding Adults training. The manager informed us that he has received safeguarding adults training in the last year and demonstrated good understanding of reporting and how to involve other agencies in the processes. The home had one adult abuse allegation in regards to resident’s expenditure since the last key inspection. The manager showed us a finance risk Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 18 assessment, which he has implemented following the safeguarding meeting, which provides additional protection of people’s finances. Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 24 and 30 during this key inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The home is well lit, clean and tidy and smells fresh. EVIDENCE: The home has undergone refurbishment work, which was lead by Metropolitan Housing Trust who owns the property. The refurbishment work has now been completed. The home is on two levels and a self-contained flat, which can accommodate four people, has been created on the first floor, this is to enable the home to move from a registered care home to a supported living scheme. The upstairs flat is nicely decorated and the kitchen has a dining area. Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 20 On the ground floor the home has provided a ceiling hoist in two of the three bedrooms and in the bathroom. Staff told us that this makes it easier to support residents who require this equipment. One resident invited me to see his room, the rooms was nicely decorated and personal items were on display. Furniture and equipment are of domestic character. Laundry can be washed on both floors. The laundry room on the ground floor has been redecorated and a semi-professional washing machine is provided. Controls of Substances Hazardous to Health items are locked away safely. The home has an infection control policy and procedure in place. Staff told us that they discuss infection control during their induction. The home was clean and free of any offensive odours during this key inspection. Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 32, 34 and 35 during this key inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service are supported by staff who are vetted and trained appropriately. EVIDENCE: Four staff hold and three staff work towards their National Vocational Qualification in Care. Altogether 60 of staff employed by the home hold or work towards National Vocational Qualification in Care. The home does not employ staff under the age of 18. The manager told us that the home recruits staff with experience in care; this however is not an essential criterion during the recruitment process. Staff will receive training in induction and in practice during their probationary period. Staff spoken to confirm this. It was agreed with Adepta and the Commission for Social Care Inspection Providers Relationship Manager in November 2008, that staff records could be Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 22 stored centrally in the Colchester or Finchley office. Staff told us that they had to provide two references, passport, medical history and a Criminal Records Bureau check during the recruitment process. The manager and deputy manager received recruitment and selection training. The manager told us that diversity issues are addressed during the interview. Staff receives copies of General Social Care Councils Code of Conduct with their handbook. We viewed training records during this inspection. All staff have attended challenging behaviour training since the last inspection. Staff have received training such as Autism, Service users risk taking, working with Diversity, Food Hygiene, Health and Safety, etc. Staff spoken to are happy with the training provided by the organisation and no concerns were raised. The manager told us that training is addressed during supervision. The home has a very good training manual in place, which provides information of forthcoming training. Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We looked at National Minimum Standards 37, 39 and 42 during this inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service benefit from a strong manager who is dedicated improving outcomes for people. Clients are involved in the decision making of the homes future. EVIDENCE: A new manager has started in March 2008; the manager has experience of running a registered care home and supported living schemes. He told us that he is currently in the process of completing his Registered Managers Award and he has National Vocational Qualification in Care Level 4. All staff spoken to Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 24 are positive about the support they receive from the manager. The manager is registered with the Commission for Social Care Inspection. We viewed the service development plan for 2007/08. This audit is very comprehensive and takes service users, staff and family views in consideration. It also looks at internal and external audits, such as Regulation 26 visits and Commission for Social Care Inspection inspections. The home is also addressing safeguarding and diversity issues in the service development plan. The manager informed us consultation meetings about the planned changes in registration have been undertaken and families, residents and stakeholders were invited to attend. We looked at a range of certificates during this key inspection, the Electrical Installation certificate is valid until 2012, the Landlords Gas Safety Certificate has been renewed, the Portable Appliances Test Certificate expires on 25/10/08, the boilers have been replaced and a Legionella test certificate is in place. The home is undertaking weekly Health and Safety checks. The fire risk assessment is up to date and regular monitoring and servicing of fire procedures and systems are undertaken. The home has a range of Health and Safety policies in place and staff have attended training. Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Adepta 49 Chichester Court DS0000062735.V372951.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!