Care Home: Grammar School House

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What the care home does well The residents benefit from having a stable staff team that are well trained and that know them well. Staff recognise the rights of residents and that they have freedom of choice. Staff provided a good level of personal support and care and residents healthcare needs are attended to promptly. The team facilitate a good level of both group and individual activities for each resident and independence and confidence is promoted. Residents who commented said that they ` liked all the staff and the manager` and ` I am happy at this home`. Residents can be assured that they would be listened to should they have a concern and the team are focused on ensuring that the home is run in their best interests. What has improved since the last inspection? Since the new manager has been in post, there have been improvements to the home and the services offered. The way that the care is organised and provided is now more person centred and focused more on individual needs. Staff training has improved over a range of subjects and this continues. Redecoration had continued in the home and this is providing a nicer environment in which to live. The manager has reviewed the complaints procedure and it is now more user friendly. What the care home could do better: The staff team need to ensure that they keep accurate records in relation to medication taken out of the home, when residents are on visits and they also need to ensure that the home`s procedures for health and safety are followed so that risks to residents are reduced as much as possible. Again the regular testing of fire safety equipment needs to be more consistent and the fire safety risk assessment for the home as a whole requires updating. CARE HOME ADULTS 18-65 Grammar School House York Road Earls Colne Colchester Essex CO6 2RB Lead Inspector Diane Roberts Unannounced Inspection 22nd October 2008 09:30 Grammar School House DS0000040901.V372877.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 Grammar School House DS0000040901.V372877.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. Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grammar School House Address York Road Earls Colne Colchester Essex CO6 2RB 01787 222412 01787 221814 grammar@consensussupport.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Grammar School House Limited David Collyer Care Home 12 Category(ies) of Learning disability (12), Physical disability (12) registration, with number of places Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability who may also have a physical disability (not to exceed 13 persons) 25th October 2006 Date of last inspection Brief Description of the Service: Grammar School House is an older style property, situated in the village of Earls Colne, with access to local towns. The home is divided into two selfcontained units, the Annexe for 5 more independent service users, and the House for 7 more dependent service users. Each side of the home has its own lounge and dining areas, and a small kitchen; both sides share laundry and garden facilities. All service users have single bedrooms. At the time of this inspection there were twelve service users in residence. The home is registered to provide care to twelve younger adults with a learning disability and/or physical disability. Although a learning disability is the primary need of current service users, one or two have an additional physical disability or medical condition (e.g. epilepsy). A statement of purpose and service user guide are available at the home. Current fees at the home range from £649 to £1,100 per week, based on information provided to the CSCI in January 2006. Grammar School House DS0000040901.V372877.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. The site visit was undertaken over a five-hour period as part of the routine key inspection. The manager was available throughout the inspection. The manager submitted a comprehensive Annual Quality Assurance Assessment, as required prior the site visit. This details their own assessment of what they do well, what could be done better and what needs improving. This information was considered as part of the inspection process and reflected as part of the report. Prior to the site visit, the manager was sent a variety of surveys to distribute and that asked questions that were relevant for each group, such as for people who use the service, relatives, staff, and healthcare professionals. Three responses were received from people who use the service and three from staff. On the day it was possible to speak to one resident and meet with others and to talk to staff in addition to the management team. A tour of the home was undertaken and a range of records relating to the home and the services offered were reviewed. What the service does well: The residents benefit from having a stable staff team that are well trained and that know them well. Staff recognise the rights of residents and that they have freedom of choice. Staff provided a good level of personal support and care and residents healthcare needs are attended to promptly. The team facilitate a good level of both group and individual activities for each resident and independence and confidence is promoted. Residents who commented said that they ‘ liked all the staff and the manager’ and ‘ I am happy at this home’. Residents can be assured that they would be listened to should they have a concern and the team are focused on ensuring that the home is run in their best interests. Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 6 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Grammar School House DS0000040901.V372877.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 Grammar School House DS0000040901.V372877.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process ensures that prospective service users’ needs are fully assessed enabling both staff and clients to be confidant that the home can meet their needs. EVIDENCE: Since the last inspection there have been no new admissions to the home. The manager reports that the assessment process remains the same and this was found to comprehensive at our last visit, with a commissioning team taking a key role. Completed assessments still remain a key part of the initial care planning process. As the manager has introduced a new person centred care planning system, he may wish to review the admission documentation to ensure that this will link in with the new approach. The manager in his AQAA states that ‘ the people living at the home would have the opportunity to meet and spend time with the potential new residents and all their views would be sort on compatibility’. Residents who commented said that they had visited the home prior to admission and that they had a choice as to whether they moved in or not. The manager has a Statement of Purpose in place along with a Service Users Guide. The Service User’s Guide has recently been updated providing a more Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 9 pictorial format. Both these documents could be improved, as outlined in the managers AQAA, by providing an audio/visual format. Grammar School House DS0000040901.V372877.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have a person centred plan in place that, where ever possible involves them and promotes their decision making and independence. EVIDENCE: Since the last inspection, the new manager has introduced a person centred care planning system into the home. Two care plans were reviewed. These were seen to be written in the first person and contained completed individual preference questionnaires, a pen picture of the person, their life history, an overview of their activities, a full assessment of need, individual ‘wants and needs’ and support plans with goals. The care plans were seen to have been completed with the residents input, where possible, and contained sufficient detail to guide and inform staff, in all areas. There is also evidence of consultation with residents and their input with regard to making decisions, for example with holidays etc. This was also evidenced during observation of staff interaction with residents. Risk assessments are in place along with care plans, to help residents develop, for Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 11 example, daily living skills. Risks were seen to be appropriately assessed and residents allowed to develop within a risk assessment framework. Staff sign to say that they have read the care plan. From discussion with residents, staff and from records, it is clear that as far as possible, residents are encouraged and enabled to lead an independent life as possible. Residents said ‘ I go out on my own to the local shops’. Other residents who commented said that they always made decisions about what to do each day. Staff spoken to, who were key workers for the residents cased tracked, knew the residents needs well and this included detail on any behavioural needs and their methods of communication. They also knew the risks that the residents may encounter in their day to day lives. Grammar School House DS0000040901.V372877.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect flexible daily routines, enabling them to engage in activities of their choice with staff supporting them to develop life skills and to maintain contact with relatives. EVIDENCE: Residents currently living at the home have a limited capacity to be engaged in employed work. From records and discussion with residents and staff, residents have a wide range of social and educational activities to take part in. Residents attend classes at local colleges, go to different drop in centres, go bowling, to shows, horse riding etc. Residents attend group activities but also have one to one time. The manager in his AQAA states that ‘service users are supported and encouraged to take up educational activities’. Records generally evidence that residents are taking part in the activities outlined in their care plans and this includes life skills such as household chores and preparing meals. The manager is keen for residents to attend social activities in the Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 13 wider community and with this in mind residents now attend a standard riding school rather than a specialist service. Residents have been able to go on holidays of their choice during the year either in a group or on their own with staff. Where staff are spending one to one time with residents the daily notes did not always show what this consisted of and more detail is needed, so that these records can be used as part of the care plan evaluation. Minutes of residents meetings show that they are consulted on activities and action plans show that suggestions are followed up and actioned wherever possible. The manager no longer employs an activities co-ordinator but these hours have not been lost but have been used to support residents in different ways. The home has a snoozelem room, which is currently being refurbished to provide a more pleasant and stimulating environment for more dependant residents. Residents do access the local community, using shops and cafes etc and residents spoken to confirmed this. More could be done to take part in local community events to develop this aspect of life in the home. The manager in his AQAA states that they could do better by ‘increasing community integration’. Residents do put on social functions in the home and friends and relatives attend these and residents also attend other functions in other registered homes. Records clearly show that residents are supported to maintain relationships with relatives and friends. The manager in his AQAA states that ‘ relationships with family and friends are actively supported by staff, some service users have regular visits to family homes, overnight stays and meals out etc’. Through observation, it was clear that the routines of the day are flexible and staff and residents discuss what to do when there is unstructured time. Residents have access to a minibus with a tail lift and a people carrier. The manager reports that there are plenty of staff to drive the vehicles and there are no limits on this. Since starting at the home the manager has stopped the online food shopping, so now residents are more involved in purchasing food and planning menus for the week. The manager and staff have also developed a pictorial menu to aid residents with food choices. The manager in his AQAA says that they have improved by ‘using fresh ingredients and less reliance on preprepared food, resulting in healthier food options’. Residents who commented said that they liked the food at the home and often went shopping for food with staff. Grammar School House DS0000040901.V372877.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were receiving appropriate support with their health and personal care giving them good outcomes. EVIDENCE: Residents care plans show that they have, where possible, choice in the way that there personal care is provided. Residents’ preferences are recorded and residents spoken to confirm that they had a key worker who they got on well with and that they could change if need be. The manager in his AQAA states that ‘residents have clear care plans which identify their support needs and preferences’. The evidence would concur with this. Records also show that residents have good access to healthcare professionals, including their GP, chiropodist and opticians etc. Residents tend to visit their GP at the surgery. Residents’ individual health needs were seen to be appropriately monitored and where necessary specialist advice had been sort. Where required staffing levels had been increased to support residents during periods of ill health. There was evidence that female residents are attending the appropriate health screening and all residents have a health action plan in place, although some of these were not dated. The manager in his AQAA states that ‘ staff act Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 15 promptly when medical problems arise, using local GP and primary care facilities or the nationals Dr’s on call system’. Residents weight was being appropriately monitored and this included risk assessments, when required. Residents were being referred to dieticians and records show that over a period of time, nutritional concerns had been addressed and overcome by the team at the home. Residents presenting with challenging behaviour had the appropriate risk assessments in place and these included details on triggers and communication with the resident. Staff spoken to, knew the residents well and could outline the risks and the management of risk in detail. The manager has a medication policy in place and the medication management was reviewed. The medication systems were found to be in good order. Residents had individual front sheets that detailed the level of support needed with medication and any other relevant information, including photos. The medication sheets were seen to be clear and neatly maintained. There are arrangements in place for residents to take medication home when they visit family etc. However, staff need to be more vigilant with regard to detailing this as anomalies were found that related to lack of recording, rather than missing medication. There was evidence that medication had been reviewed and overall the levels of medication that residents were receiving was seen to be low and appropriate. The manager in his AQAA states that ‘weekly checks are carried out by senior staff and a monthly check is carried out by the manager’. Records seen concur with this. Grammar School House DS0000040901.V372877.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has procedures in place for ensuing that service users are listened to and their concerns acted on, and for promoting the safety and protection of service users. EVIDENCE: The manager has a complaints procedure in place and since the last inspection this has been reviewed and a more user friendly, pictorial version is available. All residents spoken to and who commented said that they knew who to raise any concerns with. Residents said that they would ‘speak with the staff’. The procedure is available in the lobby, in the service users care plans and in the service users guide. No complaints have been received by the Commission regarding the home since our last visit. The manager has dealt with three complaints since our last visit and these were reviewed. Records were available regarding each complaint and these were seen to have been dealt with appropriately and objectively. One related to an incident between a member of staff and a resident, one was a neighbourly dispute and the last related to relatives consent. The manager in his AQAA states that ‘residents understand that they have the right to speak to any member of staff about any concerns they have. This is always done in private in their bedrooms, or in a quiet place of their choosing. Staff work closely with non –verbal people to read their body language and facial expressions and use communication aids when necessary’. Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 17 The manager has in place the company and local authority adult protection procedures. The manager needs to ensure that staff are up to date with the new local procedures. Staff spoken to showed an awareness of adult protection matters and residents rights. Staff training records show that 91 of staff were up to date with their adult protection training and other records showed that training was booked for October 2008 for the rest of the staff to attend. Since the last inspection two adult protection matters have been referred appropriately and dealt with promptly by the management team covering the home. Following one, the proprietor has changed procedures for the management of residents’ monies. A third adult protection matter is still being looked into at the time of this inspection. Grammar School House DS0000040901.V372877.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable and generally safe environment that is well maintained and kept clean and hygienic. EVIDENCE: A tour of the home was undertaken with the manager. All communal areas were visited and some residents were happy for us to see their rooms. Since the last inspection the home has improved as redecoration has taken place and new furniture has been purchased. This is includes lounges and at the time of our visit, the main corridors. The main lounge was seen to be very homely and comfortable. The corridor carpet in the annex is very stained and dirty and reflects poorly on the home and replacement is recommended. The home has a light and modern feel, although the building itself is old. The surroundings are appropriate for the age range of the resident group. One of the bathrooms has also been refurbished and can now be used as a wet room. Following a recent incident at the home, lockable cupboards have been installed in all the bathrooms for the storage of gloves an aprons etc. It was disappointing to note Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 19 that staff had left a key in one of the cupboards, still creating a risk for residents. The manager was noted to take this issue up with staff straight away. New worktops have been fitted in one of the kitchens and a new fridge freezer has been purchased. Residents’ bedrooms were seen to be personalised and decorated in the colours of their choice. From discussion with staff, residents who are unable to have input, have had their rooms decorated with great care, with the staff being aware of their needs, for example, with eyesight, and their personal preferences. Overall the home was seen to be clean and tidy and no odours were noted. The home has a maintenance man that visits twice and no maintenance issues were noted. Staff do check the hot water temperatures and records show that this is done regularly although all those who commented said that more maintenance visits would be of value. The home benefits from a large enclosed garden, however, limited hard standing means that some of the residents can only access a small area. This should be reviewed. This year residents have been growing their own vegetables and they have access to a new swing set and trampoline. The manager has a fire safety risk assessment in place but this was dated 2006 and needs a review. Fire evacuation risk assessments are in place for the residents and individual ones are also on file. Fire safety equipment checks take place but records show that these are inconsistent. The last fire drill was in October 2008. Grammar School House DS0000040901.V372877.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a well trained staff team, who are properly recruited to help ensure their safety. EVIDENCE: Since the last inspection there has been a low turnover of staff at the home. At the current time the manager only has 10.5 staff hours vacant and has recently recruited some new night staff who are due to start once all the required checks are in place. The current staffing levels are 6 in the morning, 6 in the afternoon and evening and 2 awake at night and one sleep in. More staff are provided at weekends to help with activities. The manager says that he is using some agency staff to cover maternity leave at the moment. Recruitment files were checked at random and found to be in good order with all the required checks and documentation in place. Records showed that all the checks had been done prior to the person commencing work. Staff have, where needed a Skills for Care induction and all staff who commented said that their induction had been very good. The manager in his AQAA confirms Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 21 that staff have a probationary period of six months and during that time they would receive an appraisal. He also states that ‘ residents have the opportunity to meet with potential staff and raise any concerns they have with staff prior to a conditional offer of employment being made’. Shortfalls in staff training, noted at the last inspection, have primarily been addressed. Records show that staff are all up to date with training on fire safety, health and safety and COSSH and there are good compliance levels with manual handling, infection control, food hygiene, first aid and adult protection. The manager has dates, in the near future, for many of the subjects where there are a few staff without the training. Training is planned for all staff on customer training and reporting. Only three staff have the learning disability qualification but 37 of the staff do have an NVQ level 2 or above. The manager reports that he is having trouble sourcing training for staff on Makaton. Grammar School House DS0000040901.V372877.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of residents, with systems in place for monitoring this. EVIDENCE: Since the last inspection a new manager has being appointed to the home and is seen to be moving the home forward in a positive way for both residents and the staff team. The manager has a background of working in residential homes for people with learning disabilities and is now the registered manager for this home. He has an NVQ level 4 and City and Guilds qualification in management for care. The manager feels that the support from the provider is good and records show that the Regulation 26’s visits are being carried out as required. Records show that the manager has been meeting regularly with the staff team and on discussion they speak positively about him and the staff team in general. The manager in his AQAA Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 23 states that ‘the manager an deputy manager set high standards which evidence good practice values and leadership. This is conducted via supervision and work practice. Shifts are worked (by the manager) on a regular basis to deliver hands on support in order to maintain good relationships and communication skills with both the service users and the staff team’. The manager has a quality assurance system in place. Each year residents are asked to complete a feedback questionnaire. These are analysed and action is taken where required to address any issues. Copies of the last feedback analysis was seen and the results were very positive with residents being asked about, for example, their care and support, making choices, being listened to, and where they live. Each month the manager also has to complete an internal audit system, covering, for example, staffing, training, accidents, incidents and complaints, catering, the environment, medication and care. It is interesting to note that the audit asks whether the manager has met with staff but not with residents. Records show that the manager has met with residents and the minutes show that input is encouraged from them and their opinions are noted and acted upon. The home had an appropriate Health and Safety policy, and the manager advised that the home had a range of other health and safety information and guidance that was available to staff and gone through at induction. Shortfalls in relation to health and safety have been commented on in a previous section. (Environment). Grammar School House DS0000040901.V372877.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 X 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 2 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 2 x 3 X 3 X X 2 X Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Appropriate records must be maintain for residents taking medication home to ensure that they can be accounted for. The registered person must ensure there is evidence of the regular testing/checking of all fire equipment. This is a repeat requirement. Staff need to follow the home’s procedures in order to keep residents free from risks as far as possible. This relates to keeping lockable cupboards locked. This was advised on the day of the inspection. Timescale for action 31/12/08 2. YA24 23(4) and 17, schedule 4.14 13(4) 14/12/08 3. YA42 22/10/08 Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 26 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. 2. Refer to Standard YA12 YA13 Good Practice Recommendations Staff need to evidence what they are doping when they are spending one to one time with residents to help provide meaningful information for evaluation. Staff at the home should explore ways that the residents can be increasingly part of the local community. Grammar School House DS0000040901.V372877.R01.S.doc Version 5.2 Page 27 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 Grammar School House DS0000040901.V372877.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. 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