Care Home: Gascoigne Road, 80

What the care home does well Overall, the inspector was satisfied that this is a well run home, and that service users receive good levels of care and support. Staff were seen to interact with service users in a friendly and respectful manner, and service users spoken to informed the inspector that they were happy at the home. One commented "It`s good." While another said "I like it here." Care planning in the home was of a good standard, as was record keeping generally. Service users are offered a varied, balanced and nutritious diet, and have access to relevant health care professionals as appropriate. What has improved since the last inspection? There have been improvements to the home since the last key inspection, and the inspector was pleased to note that all of the eleven requirements made at the previous inspection have now been met. The home now carries out comprehensive pre admission assessments of any prospective service users, and the service users files are now up to date. Bedrooms are now homely and well decorated, in line with service users choices. Safety checks are now carried out, including those covering fire equipment. What the care home could do better: There are still some issues that must be addressed, and a total of three requirements have been made in this report, along with one good practice recommendation. In particular, the home must ensure that service users have access to regular community based social and leisure activities, including atthe weekends. The home must also repair the broken bath, and replace missing tiles in bathrooms. CARE HOME ADULTS 18-65 Gascoigne Road, 80 80 Gascoigne Road Barking Essex IG11 7LQ Lead Inspector Rob Cole Unannounced Inspection 20th January 2008 10:00 DS0000067244.V358177.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 DS0000067244.V358177.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. DS0000067244.V358177.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gascoigne Road, 80 Address 80 Gascoigne Road Barking Essex IG11 7LQ 0208 724 1614 0208 724 1615 linda.neaves@lbbd.gov.uk 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) London Borough of Barking & Dagenham Linda Neaves Care Home 12 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0) of places DS0000067244.V358177.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2006 Brief Description of the Service: 80 Gascoigne Road is a purpose-built care home run by Barking and Dagenham Council. It provides accommodation and support for up to twelve people who have a learning disability, some of whom also have a physical disability. Opened in December 2005, it was the modern replacement for the old-style York House. The new building is a spacious bungalow, with lots of design features to help those who use wheelchairs - such as wide corridors and doorways, large bedrooms with en-suites, and specially equipped bathrooms. It is set well back from the busy Gascoigne Road in Barking, close to shops, transport networks and other local amenities. The fees charged by the home are £777 per week. DS0000067244.V358177.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 inspection took place on the 20/01/08 and was unannounced. The inspector had the opportunity of speaking with service users and staff from the home, and the inspection also included a follow up telephone conversation with the homes manager, who was not present during the site visit. The inspection also included an examination of documents and other records. The inspector was able to observe staff interactions with service users, and this has helped to form judgements made within this report. The home completed an Annual Quality Assurance Assessment (AQAA) prior to this visit, and this formed part of the overall inspection process. What the service does well: What has improved since the last inspection? What they could do better: There are still some issues that must be addressed, and a total of three requirements have been made in this report, along with one good practice recommendation. In particular, the home must ensure that service users have access to regular community based social and leisure activities, including at DS0000067244.V358177.R01.S.doc Version 5.2 Page 6 the weekends. The home must also repair the broken bath, and replace missing tiles in bathrooms. 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. DS0000067244.V358177.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 DS0000067244.V358177.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home provides prospective service users with sufficient information about the home to enable them to make an informed choice as to move in or not. This information is provided through documentation, and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose in place. This states that “80 Gascoigne Road aims to offer people with severe learning disabilities and additional needs the opportunities to live a normal a life as possible, offering person centred support to participate as active citizens in the local community.” The Statement includes details of the manager, the staff team and their qualifications, the organisational structure of the home and the arrangements for social and leisure activities. The Statement is subject to regular review, and is written in plain English. The home also has a Service User Guide, and all service users have been provided with their own copy. This has been produced in plain English and in audio format, to help make it more accessible to service users, and to meet their needs around equalities and diversity issues. The Guide includes details DS0000067244.V358177.R01.S.doc Version 5.2 Page 9 of the homes physical environment and of its complaints procedure, and is in line with National Minimum Standards (NMS). The home has an admissions procedure in place. This states that a pre admission assessment will be carried out, and that a transition plan will be drawn up which will involve the service user having a chance to visit the home before deciding if they wish to move in or not. Service users will initially move in on a three month trial basis, after which a placement review meeting will be held. The inspector was pleased to note that pre admission assessments have been developed and improved since the previous inspection, and are now of a satisfactory standard. Assessments are carried out on a standard pro forma, which include a series of tick boxes, plus space to provide other relevant information, such as what are preferences around food, or what support is needed with getting dressed. Assessments also cover needs around medication; personal care, social and leisure needs and needs around equalities and diversity issues. All service users have been provided with a written contract/statement of terms and conditions. These are signed by the service user and a representative of the home. They include details of services and facilities provided, fess payable, what the fees cover and what is extra. DS0000067244.V358177.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that service users have a large degree of control over their daily lives, and are supported to make choices around their care and the day to day running of the home. EVIDENCE: Individual care plans are in place for all service users. These are of a good standard, clear, comprehensive and subject to regular review, including an annual review which is attended by the service users social worker. Relatives are also invited to the review meetings, which the service user also attends. Plans are sufficiently detailed to provide clear information on how the home and staff are meeting the needs of service users, for example giving information on what support is needed with brushing teeth or eating a meal. DS0000067244.V358177.R01.S.doc Version 5.2 Page 11 Plans also cover needs around health, mobility, social and leisure needs and equality and diversity issues such as religion or disability. As with care plans, risk assessments are also of a good standard, and subject to regular review. Risks are identified, and strategies are in place to manage and reduce these risks. Assessments make clear that service users are supported to take reasonable risks, for example, one service user has little understanding of the value of money, and is at risk of financial abuse. However, they like to hold and spend their own money, which helps to promote their dignity and independence. Controls have been put in place to help prevent the risk of abuse, but the service user is still able to hold and spend their own money. Through observation and discussion there was evidence that service users have a large degree of control over their daily lives, for example when to get up, go to bed, what to wear etc. Service users are also able to choose what clothes they buy. Due to the nature of their disabilities, service users have only limited involvement in the day to day running of the home, but it was positively noted that the home has made efforts to consult service users and to enable them to make choices wherever possible. For instance, the home has produced picture books around food and activities which help service users to make choices, while one service user has their own communication book which enables them to communicate with staff, for example if they would like a drink or want to use the toilet. The home uses an advocate who regularly meets with service users, and helps facilitate service user meetings. Service users have been involved in choosing décor for their bedrooms, for example one bedroom had a pink colour scheme, and the service user confirmed that this was their choice. The home has a confidentiality policy in place. This includes information on when a confidence may have to be broken in the health, safety and welfare interests of service users and others. Staff spoken to demonstrated a good understanding of the issues around confidentiality. Confidential records are stored securely, and service users and staff can access their records as appropriate. DS0000067244.V358177.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 and 17. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector believes that generally service users are supported to live valued and fulfilling live, but that they would further benefit from more opportunities to participate in community based social and leisure activities. EVIDENCE: No service users are currently involved in any formal education or employment opportunities. Three service users regularly attend day services, where they participate in various activities such as music and art groups, gentle exercise and community awareness. Day services also provide the opportunity for service users to develop and maintain friendships, and one service user informed the inspector that they like to go to their day service, as they have a lot of friends there. Two service users are supported to go to church regularly. DS0000067244.V358177.R01.S.doc Version 5.2 Page 13 Service users are involved in domestic routines to help develop independence, for example with cooking sessions and laundry. In house service users have access to a variety of activities, including music, TV, videos, massage, beauty treatments, aromatherapy and one service user plays their own guitar. Several service users recently went on a holiday to Butlins, the inspector was informed that service users were involved in choosing this destination. The homes Statement of Purpose says that “Our aim is to support service users to have access to, and choose from, a range of appropriate leisure activities.” Records are maintained of activities, but these indicated that some service users have very little access to community based social and leisure activities. For instance, records indicated that in the past six months the only time one service user had been into the community was a visit to Barking market, while over the same period another service user had also only been out once, this time to Romford for shopping and lunch out. Records further indicated that there was very little opportunity for any service users to access the community at weekends. It is required that arrangements are made for service users to have regular access to community based social and leisure activities in line with their stated preference and assessed needs, including over the weekends. The home has a visitor’s policy in place, and visitors are welcome at any reasonable time. Service users can see visitors in private if they so wish. Service users have access to a telephone, one service user was observed to tell staff they wished to phone their parents, this was seen to be arranged. One service user has their own mobile phone. Staff support service users with reading any mail received. Records are maintained of menus, these indicated that service users are offered a varied, balanced and nutritious diet. On the day of inspection there was a choice of sausages or lamb chops both served with fresh vegetables and roast potatoes, which appeared appetizing. Fresh fruit was available, and staff were observed to offer drinks and snacks throughout the day. Mealtimes were seen to be relaxed and unhurried, and support provided with eating was done in a sensitive manner. The kitchen was clean and tidy, and food was stored appropriately. Records are maintained of fridge and freezer temperatures, and cooking staff have undertaken training in food hygiene. There was evidence that service users are involved in menu planning, and that the home sought to meet peoples needs around equalities and diversity by offering culturally appropriate food. However, staff informed the inspector that service users did not generally have the opportunity to accompany staff when they went food shopping, and it is recommended that they be given this opportunity. This would increase the amount of choice they had over food bought, and provide an opportunity of participating in the local community. DS0000067244.V358177.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is meeting the personal and health care needs of service users. Service users have access to relevant health professionals, and medication is administered appropriately. EVIDENCE: Care plans indicate that service users are supported to manage their own personal care as much as possible, to help promote and develop their independence and dignity. For example service users are supported to choose what clothes to wear, and all were appropriately dressed on the day of inspection. Staff were observed to knock and wait before entering bedrooms respecting the privacy of service users. The home operates a keyworker system, and keyworkers spoken to demonstrated a good understanding of the individual needs of the service user they keywork. To help meet needs around equalities and diversity issues the home ensures that female staff provide intimate personal care to female service users. DS0000067244.V358177.R01.S.doc Version 5.2 Page 15 All service users are registered with a GP. Clear records are maintained of medical appointments, including details of any follow up action necessary. Records indicate that service users have access to health care professionals as appropriate, including dentists and opticians. The home makes use of the Continence Advisory Service, and used continence products are disposed of appropriately. The home runs gentle exercise classes to help service users with their mobility and general health and fitness. The home has a medication policy in place. Only staff that have undertaken training are able to administer medications. Medications are stored in a locked cabinet, inside a locked medication room, or in a designated medication fridge which is kept in the same room. The home checks the fridge temperatures on a daily basis. The home’s medication is supplied by Boots pharmacy, and they carry out periodic inspections of the homes medications practices. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. All medications are administered by two persons, so they can check each others work, to help reduce the risk of errors occurring. Medication Administration Records are maintained, those checked by the inspector were accurate and up to date. DS0000067244.V358177.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home has made suitable arrangements to help ensure that service users are protected from the risk of abuse, through staff training and appropriate policies and procedures. EVIDENCE: The home has a complaints log, this evidenced that any complaints received are recorded and investigated as appropriate. There was also a complaints procedure, a copy of which was on display within the home. All service users are given a copy of the procedure within the Service User Guide. The procedure includes contact details of the CSCI, and timescales for responding to any complaints received. The procedure has been produced in pictorial form to help make it more accessible to service users. The home is run by the London Borough of Barking and Dagenham, and operates within its adult protection policy and procedure. To this end a copy of the procedure is kept in the home and available to staff for reference as appropriate. Staff spoken to during the course of the inspection have all undertaken training around adult protection issues, and demonstrated a good understanding of their roles and responsibilities around adult protection. The home keeps money on behalf of service users in a locked safe, and only the manager and the homes administrator have access to this. Some money is DS0000067244.V358177.R01.S.doc Version 5.2 Page 17 left in the petty cash tin for use when the manager or administrator are not available. Records and receipts are maintained of financial transactions involving service users monies. DS0000067244.V358177.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): 24,25,26,27,28,29 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home is suitable to meet its stated purpose with regard to its physical environment. Service users are provided with adequate private and communal space, and the home was generally well maintained. EVIDENCE: The home is situated in residential area of Barking, in the London Borough of Barking and Dagenham. It is close to shops, transport links and other local amenities. The home was purpose built for adults with learning disabilities, with additional physical disabilities. As such there are adaptations in place around the home to help make it accessible, for example it is built over one floor, corridors and doorways are wide, and baths, showers and toilets have been adapted. DS0000067244.V358177.R01.S.doc Version 5.2 Page 19 Communal areas include a spacious sitting room/dining room, a smaller dining room, a visitor’s room, a kitchen and garden space, including a lawn area and a patio, with appropriate garden furniture. The home was generally well maintained, both internally and externally. Furniture and fittings were well maintained, and domestic in character. All service users have their own bedrooms, which are ensuite. Bedrooms meet NMS on size requirements. Service users have been able to personalise their bedrooms to their own individual tastes, for example with family photographs and televisions. As mentioned, service users have also been involved in choosing the décor for their rooms. Bedrooms were clean and tidy, and staff informed the inspector that service users are involved in helping to keep their rooms tidy. All bedrooms have under floor central heating, along with adequate natural light and ventilation. Carpets, bedding and curtains were well maintained, and domestic in character. Bedrooms contained adequate furniture, including table, chairs, chest of draws and a wardrobe. In addition to the ensuite toilets in bedrooms, there are several communal toilets, along with baths and showers. The inspector was satisfied that toilet and bathing facilities are sufficient in number to meet the needs of service users. Both baths and showers have been adapted to make them accessible to service users, and enabling them to have a choice. Bathrooms were clean, tidy and free from offensive odour, and all had working locks including an emergency override device fitted. However, it was noted that one of the baths was not working, staff were unsure how long this had been broken, but said that it was at least two weeks. It was further found that there were missing tiles from the walls in two of the bathrooms, and both of these issues must be addressed. Laundry facilities in the home were suitable in scale to meet the needs of service users. The home has taken steps to help prevent the spread of infection. Protective clothing such as gloves and aprons are available to staff, and hand washing facilities are situated around the home. COSH products were stored securely. DS0000067244.V358177.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): 31,32,33,34 and 35. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is staffed in sufficient numbers, and that the staff team are suitably qualified and experienced to meet the needs of service users. EVIDENCE: The home provides 24-hour support, plus an emergency on-call back up. Five staff work the early shift, four the late shift and two waking and one sleep-in staff work at night. There was a staffing rota on display within the home, this accurately reflected the staffing situation on the day of inspection. However, the rota did not include the hours worked in the home by the manager. In order to verify that the manager spends sufficient time in the home to manage it effectively, and to let service users and staff know when the manager will be working, it is required that their hours are clearly recorded on the staff rota. Through observation and discussion there was evidence that staff have a good understanding of their roles and responsibilities and of the individual and collective needs of service users. All staff are provided with a copy of their job DS0000067244.V358177.R01.S.doc Version 5.2 Page 21 description. There is a staff handover at the beginning of every shift, and regular staff meetings take place. Staff demonstrated a good ability to communicate with service users, some of whom have complex communication needs, for example through sign and picture books. Staff were seen to interact with service users in a friendly and respectful manner, and several instances of positive staff interactions were seen throughout the course of the inspection. These included singing and dancing with service users, who appeared to be enjoying these activities. The inspector spoke with several staff members, who said that they had undertaken a comprehensive induction programme on commencing work at the home. This included a period working supernumery, where they had the opportunity of shadowing more experienced members of the staff team. There is an on going training programme, and recent staff training has included medication, health and safety, infection control and food hygiene. Staff said they were booked to attend training around challenging behaviour in the near future. The AQAA provided by the home states that over 50 of care staff have obtained an NVQ Level 2 in Care or equivalent qualification, thus meeting the NMS. The home has various employment related policies in place, for instance on equal opportunities and recruitment and selection. Staff employment records and supervision records are stored securely within the home, and the inspector did not have access to these on the day of inspection. At the previous inspection these were found to be satisfactory, and will be tested again as part of the next key inspection of the home. DS0000067244.V358177.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): 37,38,39,40,41,42 and 43. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It the view of the inspector that this is a generally well managed home. For instance, appropriate checks are in place around health and safety and quality assurance. EVIDENCE: The homes Statement of Purpose contains details of the managers qualifications and experience, and these indicate that these are appropriate to the role. Staff spoken to during the course of the inspection said that they found the manager to be approachable and accessible. DS0000067244.V358177.R01.S.doc Version 5.2 Page 23 The home has policies and procedures in place in line with NMS. Those checked by the inspector included adult protection, confidentiality and complaints, and were of a satisfactory standard. Record keeping in the home was of a generally good standard. Confidential records are stored securely, staff and service users can access their records as appropriate. The home has a quality assurance policy in place. Care plan reviews and staff meeting contribute to the quality assurance within the home. Copies of previous inspection reports were available to view in the home. As mentioned, service users have access to an advocate, which helps to enable them to express their views, and provide feedback on the care and support they receive, thus contributing to the quality assurance process within the home. Staff have undertaken various health and safety related training, such as infection control and food hygiene, and the home has appropriate health and safety policies in place. Fire extinguishers were situated around the home, these were last serviced on the 5/10/07. Fire exits were clearly signed and free from obstruction. The AQAA contained evidence that the home has had gas safety, PAT and electrical installation checks carried out within appropriate timescales. The home regularly tests its fire alarms, and holds regular fire drills. Emergency call point alarms are fitted in all bedrooms, and the inspector activated one of these and was pleased to note that staff attended to the call within 30 seconds. COSHH products were stored securely. The home has in date employer’s liability insurance cover in place. DS0000067244.V358177.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 3 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 3 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 3 3 3 DS0000067244.V358177.R01.S.doc Version 5.2 Page 25 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA14 Regulation 16 Requirement The registered person must ensure that service users are supported to access regular community based social and leisure activities in line with their assessed needs and stated preference, throughout the week, including at weekends. The registered person must ensure that the broken bath is repaired. The registered person must ensure that missing tiles in bathrooms are replaced. The registered person must ensure that the staffing rota accurately records the hours worked in the home by all staff, including the homes manager. Timescale for action 31/03/08 2. YA27 23 31/03/08 3. YA33 17 29/02/08 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 Good Practice Recommendations DS0000067244.V358177.R01.S.doc Version 5.2 Page 26 Standard DS0000067244.V358177.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000067244.V358177.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. 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