Care Home: Freedom Care Ltd (70 Conway Drive)

What the care home does well The people who live in the home always have one-to-one support and additional support is available if required. This means there is always staff available to support them and people said that they could do what they wanted to during the day, at evenings and at weekends. People attend college, go out for day-trips, go to the theatre, attend football matches and a range of other activities. People are also well supported to maintain contact with their families and take part in family celebrations.The people who live and work at the home get on well together and people said that they liked the people who supported them and the manager. Both people said that they would tell the manager if they weren`t happy about anything. Both people said that they liked living in the home and were proud to show off their rooms, which contained lots of their own things. People are encouraged to do things in the home such as shopping and cooking and are supported to develop their skills in these areas. Staff receive very good training and support so that they can meet people`s needs, which are clearly outlined in Individual Plans. People are involved in writing their own plans and saying how they like to be supported. Speech and Language therapists have worked with the staff and the people who live at the home to make sure that they communicate well with each other. This makes it less likely for people to get frustrated because they don`t understand. Key workers ask people if they are happy with the support they receive every month and the manager also asks other people involved with them, such as their relatives, if they are satisfied with the service the home provides. What has improved since the last inspection? No requirements or recommendations for improvement were made at the previous inspection. What the care home could do better: There have been some changes in the Regulations about how certain drugs (called controlled medication) should be stored in care homes. This means that the people who own 70 Conway Drive must make sure that they have a special metal cabinet, fixed to a solid wall so that they can store these drugs if any of the people living in the home need to take them in the future. The registered manager and staff team`s knowledge of current local multiagency procedures, which safeguard and protect people would benefit from accessing training in these areas available from the Local Authority. CARE HOME ADULTS 18-65 Freedom Care Ltd (70 Conway Drive) 70 Conway Drive Shepshed Loughborough Leicestershire LE12 9PP Lead Inspector Ruth Wood Unannounced Inspection 18th June 2008 09:30 Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.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 Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.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. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Freedom Care Ltd (70 Conway Drive) Address 70 Conway Drive Shepshed Loughborough Leicestershire LE12 9PP 01509 821185 01509 821185 joe@freedomcare.org 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) Freedom Care Ltd Mr Joseph Matthew Kinch Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 18th June 2007 Brief Description of the Service: Freedom Care Limited at 70 Conway Drive is in a quiet residential area in the village of Shepshed in Leicestershire. The home is registered for a maximum of two people with learning disabilities. The home is a converted detached bungalow. To the ground floor of the property there is a lounge, dining room, kitchen, main bath and shower room, and homes’ office. Resident’s bedrooms are situated on the first floor. There is a small garden at the rear of the home, which residents can use. At the back of the garden there is a snoozelum room for residents to relax in and enjoy. Also there is a converted garage which is used for meetings and storing documents. The manager provides, upon a request or enquiry, an information pack, which includes Service User Guide and statement of purpose. This means that people will have all the information about the service provided by this home and how much it will cost. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.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 3 stars. This means the people who use this service experience excellent quality outcomes. The inspection visit took place on a weekday between 09:30am and 13:10pm. As well as this visit, information to inform this report was also drawn from the following sources: • The Annual Quality Assurance Assessment (AQAA); This is a selfassessment, that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. • Responses from the two people who live in the home to questionnaires sent out by the Commission for Social Care Inspection asking for their opinions about living at 70 Conway Drive. • Responses from two staff members to questionnaires about the quality of management, training and support they receive. • One response from the relative of a person who lives in the home who gave their views on the quality of care their relative receives. During the inspection visit, people’s individual plans were seen and discussed with the registered manager and staff members and the interaction between the people who live and work in the home was observed. The inspector spoke to the people who live in the home, saw their rooms and the rest of the rooms in the house and looked at photographs of the activities that they had taken part in. The inspector also spoke to staff about their training and the kind of support they receive and looked at their recruitment, training and development records. How people are supported to manage their finances and medication was also looked at. What the service does well: The people who live in the home always have one-to-one support and additional support is available if required. This means there is always staff available to support them and people said that they could do what they wanted to during the day, at evenings and at weekends. People attend college, go out for day-trips, go to the theatre, attend football matches and a range of other activities. People are also well supported to maintain contact with their families and take part in family celebrations. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 6 The people who live and work at the home get on well together and people said that they liked the people who supported them and the manager. Both people said that they would tell the manager if they weren’t happy about anything. Both people said that they liked living in the home and were proud to show off their rooms, which contained lots of their own things. People are encouraged to do things in the home such as shopping and cooking and are supported to develop their skills in these areas. Staff receive very good training and support so that they can meet people’s needs, which are clearly outlined in Individual Plans. People are involved in writing their own plans and saying how they like to be supported. Speech and Language therapists have worked with the staff and the people who live at the home to make sure that they communicate well with each other. This makes it less likely for people to get frustrated because they don’t understand. Key workers ask people if they are happy with the support they receive every month and the manager also asks other people involved with them, such as their relatives, if they are satisfied with the service the home provides. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.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 Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is excellent Good information about the home and excellent assessment procedures ensure that people can be confident that the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Service Users Guide is written specifically for each individual living in the home. Responding to the Commission’s survey, both people living at the home felt that they had received enough information about the home before they moved in. Both people living in the home have very comprehensive assessments in place, which cover all aspects of their needs and aspirations. There is evidence that these are regularly updated and modified to take account of any changes in need. As there have been no new admissions to the service in the past 6 years, it was not possible to directly inspect the admissions process within 70 Conway Drive. Comprehensive procedures for the admission of new people to the home are in place and this process was inspected as part of the inspection of 68 Conway Drive. These procedures give plenty of opportunity for people to visit the home and ‘test –drive’ it before they move in. The manager and senior staff team are also very pro-active in gathering information to inform their assessment, to ensure that they can meet people’s needs. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.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): 6,7,9 Quality in this outcome area is excellent Exceptionally well written and detailed individual plans ensure that people’s needs are met, that risk is well managed and that people are supported to make choices and decisions about their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual plans are very detailed and compiled with the involvement of the people concerned. They are person-centred, written from the person’s perspective and use pictures and photographs as well as the written word to convey information. Plans give staff exceptionally clear direction as to how people’s needs and aspirations should be met. Two staff who completed the Commission’s survey felt they were always given up-to-date information about the needs of people they support and that they had the right knowledge to support people’s diverse needs. The two staff on duty at the time of the inspection agreed with this view. A key worker system is in place and staff’s responsibilities are outlined and they have received training to explain the purpose of this role. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 11 A communication plan is in place for each person and this has been compiled with the ongoing input and support of speech and language therapists. Exceptionally clear guidance is given to staff about the most appropriate methods to use to enable people to communicate without becoming frustrated and to encourage appropriate behaviour and responses. A mixture of speech, Makaton and pictures/symbols is used and staff were observed to follow this guidance during the course of the inspection. In response to the Commission’s survey both people who live in the home said that they could make decisions about what to do each day and could do what they wanted during the day, evening and at the weekend. Staff were observed to offer choices as to personal routines (such as getting washed and dressed) meals and activities and allowed people time to respond. Risk assessments are exceptionally clearly written and cross-referenced to other areas of a person’s plan so that an audit trail is available to explain any necessary restrictions on behaviour. Individual plans also contain details about the kind of additional training that staff should have to undertake certain activities with people. One relative commented on the person-centred nature of the care offered, “Everything the person in care wants comes first” and said that the home always meets their relative’s needs and always gives the care agreed or expected. Detailed notes of people’s finances are kept and good systems are in place to ensure that people’s financial interests are safeguarded. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.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 excellent People’s lifestyles reflect their needs and aspirations; they are supported to make choices and take part in appropriate activities within the local community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person has an individual timetable of activities and receives one-to-one support from staff at Conway Drive to engage in these. People attend Further Education College, go horse riding, go walking, and visit local facilities such as garden centres and other places of interest. One person has pursued a drama course at college and pictures of their most recent productions were included in their individual plan. Although the home has its own transport, people also use public transport, one person said, “I like to go on the bus and go on the train to Leicester”. People also go on holiday with staff support and also invite friends to barbecues (weather permitting) and other social events. At lunchtime on the day of the inspection, people were discussing a trip to the garden centre that afternoon, what plants they would buy, what plants needed putting in the garden and Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 13 who was going to do it. One person has a season ticket to Leicester City Football Club and is supported to attend all home matches. People are also supported to take annual holidays and go on a variety of day trips such as theatre visits to London. People are supported to maintain contact with their families. One person said they would soon be going on a trip with their Father and one relative in response to the Commission’s survey said that the home always kept them upto-date with important issues. People are supported to telephone their families and to attend family celebrations. One person had recently attended their sister’s wedding and was proud of the photographs of the occasion. People are supported and encouraged to develop ‘skills for life’ such as choosing the correct clothes for an occasion and making a cup of tea and being involved in the day-to-day activities of the home. People are involved in shopping and food preparation (including baking) and receive appropriate levels of support to engage in these activities; for example picture- shopping lists are used. A record is kept of what each individual person has eaten. People are encouraged to make choices about what they would like to eat while being given appropriate guidance to ensure that they eat a nutritionally balanced diet. Staff and the people who live in the home eat together and meals are an opportunity for them to discuss their plans for the day and share conversation. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.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 excellent People’s personal care, health and medication needs are well met This judgement has been made using available evidence including a visit to this service. EVIDENCE: Details of people’s health and personal care needs are contained within a health action plan, which they have been involved in compiling. Information about the kind of support the person would like and requires to access GP, optical and dental services is written down together with a record of all medical appointments. Evidence that people have access to various dental, optical and other services is contained in letters and prescriptions, which are kept together with the person’s individual plan. People have given consent for staff to administer their medication and clear guidance is in place stating who and under what circumstances ‘as required’ medication can be given. Letters from consultants indicate that people’s medication is reviewed every 3 to 6 months depending on the nature of the medication taken and the complexity of the regime. All medication administration records were completed fully and accurately and a record is made of medication being received into and leaving the home. Staff have received training in the administration and management of medication and those on duty discussed a higher level course delivered by Boots the Chemist that they are currently undertaking. They felt this gave them a good insight Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 15 into the kinds of medication that people were taking and the possible side effects. Amendments to Regulations relating to the Misuse of Drugs mean that the home must have separate storage for controlled medication. This should be a metal cupboard of specified gauge with a specified double locking mechanism. It should be fixed to a solid wall or a wall that has a steel plate mounted behind it with Rawl or Rag bolts. No controlled medication is currently stored or administered in the home. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.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 Good procedures and practice ensures that people are protected and can voice any concerns This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person has an easy-to-read copy of ‘How to make a Complaint’ in their rooms. Responding to the Commission’s survey both people said they knew who to speak to if not happy, that staff always treated them well and listened and acted on what they said. During the inspection they said that they would tell the manager if they weren’t happy and both were observed to have an open and friendly relationship with him. One relative who responded to the Commission’s survey said that they knew how to make a complaint but had never needed to. All staff receive training in recognising adult abuse and the protection of vulnerable adults; this is updated annually. It is recommended that the manager and staff access training provided by the County Council in the local multi-disciplinary protocols for safeguarding adults, to ensure that they are fully aware of current local practice. Clear plans are in place outlining how behaviour which may challenge should be managed and staff receive regular training in responding appropriately to such behaviour; again this training is updated annually. Staff said that they felt confident in working with the two people who live in the home and that they had received appropriate training to be able to meet their needs. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 17 All staff have criminal records bureau checks and have their names checked against the vulnerable adults register before they start working in the home. This helps to make sure that only suitable people work at 70 Conway Drive. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.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, 30 Quality in this outcome area is good People live in a homely, comfortable and clean environment which meets their needs This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person proudly showed the inspector their bedroom and these reflected their individual personalities and interests. The home is clean, comfortable and well furnished and has recently been redecorated and refurbished. The bathroom has a spa bath which one person enjoys using. All staff have received training in infection control and the home appeared fresh and clean throughout; both people who live in the home said that the home was always fresh and clean. The home has been recently inspected by Local Authority Environmental Health and gained three stars – the highest level for its food hygiene arrangements Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.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, 36 Quality in this outcome area is excellent People receive excellent support from a very well trained, effectively managed staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a very clear plan for workforce development looking at the needs of individual staff based on needs of the people living in the home and developing an overall plan to ensure that the workforce has the necessary ongoing skills to support them. Courses recently attended by staff have included communication training, training in the implications of the Mental Capacity Act, training in how to be an effective key worker and key counselling skills. All staff members have or are undertaking National Vocational Qualifications in supporting people. Staff were very positive about the quality of training and support that they receive both in their responses to the Commission’s survey and during the inspection. Comments included, “my induction was excellent”, and described management and the rest of the team as “supportive” and said they received “excellent training by brilliant tutors”. Staff said that training was relevant to their role, helped them to understand people’s needs and kept them up-todate with new ways of working. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 20 The people who live in the home always have one-to-one support and additional support is available if required. Interaction between the people who live in the home and the staff who work with them was observed to be friendly and open and it was clear that a good, trusting relationship had been developed. Staff records were examined – these contained a detailed application form, notes of the interview process, two written references, medication questionnaire and evidence of criminal records bureau checks and checks against the vulnerable adults register. All staff also have a performance and development plan and receive regular supervision from the registered manager. As part of the supervision process staff complete a pre-supervision form to help identify areas to focus on and also complete a form to give feedback on how they feel the process went and if their support needs are being met. Formal supervision such as this takes place once every three months but the registered manager is ‘very hands on’ and is available for staff to consult with on an ongoing basis. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.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, 38, 39, 42 Quality in this outcome area is excellent Good management and effective quality assurance systems ensure that the home is run in the best interests of the people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has over ten years experience of working with adults with learning disability and autism. He holds the Registered Manager’s Award, a National Vocational Qualification in care and support at level 4 and seeks to constantly update his knowledge about current practice through attending relevant training and through research on appropriate websites such as the CSCI professional site. Discussion was held with the manager about his efforts to ensure both he and his staff were aware of the implications of the new Mental Capacity Act for how people were supported within the home. The registered manager places great emphasis on ensuring that people are happy with the service they receive. Each month they complete a satisfaction questionnaire and discuss if they are satisfied with the service with their key Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 22 worker. Staff receive regular formal supervision and monthly staff meetings are held. A formal quality review is conducted every 6 months where in addition to people who live and work in the home, other stakeholders such as relatives and professionals are formally surveyed to find out their opinions on the standard of service offered. A formal report, which includes comments from stakeholders is produced and used to inform the way is developed and run. Fire Alarms were tested on the day of the inspection and the Annual Quality Assurance Assessment (AQAA) completed by the registered manager contained details of when gas, electrical and fire systems were checked and serviced. A fire alarm test took place during the inspection and this was appropriately recorded. All staff have received training in food hygiene, moving and handling, first aid and health and safety. Records indicate that fire alarms are regularly tested and risk assessments are in place covering safe working practices in the home. Leicestershire County council undertook an inspection of the home’s food hygiene standards in June 2008 and awarded the home the highest – 3 star assessment for their management of food hygiene in the home. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.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 4 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 4 33 X 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 4 4 X X 3 X Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? X 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 OP9 Regulation 13(2) Requirement Secure storage must be put in place for controlled drugs to meet the requirements of the Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007 Timescale for action 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA23 Good Practice Recommendations It is recommended that the manager and staff access training provided by the county council in the local multidisciplinary protocols for safeguarding adults to ensure that they are fully aware of current local practice in this area. Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Freedom Care Ltd (70 Conway Drive) DS0000035080.V366688.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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