Care Home: Hope House

Similar services:

• Herbert Street
• Charis
• Hartley House
• Brook Drive, 124
• Rugby House Project
• City Roads Crisis Intervention

What the care home does well What has improved since the last inspection? This was the first inspection of the service under a new registration. What the care home could do better: A procedure must be established for staff to follow in the event that a client refuses to take prescribed items of medication. Staff should have access to information about the medications clients are prescribed. Quality assurance systems must be strengthened by the completion of reports of visits made on behalf of the Registered Provider. CARE HOME ADULTS 18-65 Thurston House 52 Rectory Grove Clapham London SW4 0EB Lead Inspector Alison Pritchard Key Unannounced Inspection 7th January 2008 11:15 DS0000070373.V357416.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 DS0000070373.V357416.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. DS0000070373.V357416.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thurston House Address 52 Rectory Grove Clapham London SW4 0EB 0207 622 7833 020 7498 0663 anitah@thecdc.org.uk www.actiononaddiction.org.uk Action on Addiction Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) See standard 37 Care Home 23 Category(ies) of Past or present alcohol dependence (23), Past or registration, with number present drug dependence (23) of places DS0000070373.V357416.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2007 Brief Description of the Service: Thurston House is a care home providing personal care and accommodation for up to 23 men under the age of 65 who are recovering from substance misuse. The home is managed by Action on Addiction. The home is located in a quiet residential area a few minutes walk from Clapham Common and a shopping area with many community facilities. Transport routes (tube, bus and rail) are close by. The home is a large detached Grade II listed Georgian house on three floors plus a semi-basement. All of the home’s bedrooms are shared, in line with its beliefs on the value of peer support and the discouragement of secrecy. The home is not accessible to people with restricted mobility as there are steps to the front door and no lift is possible due to the listed status of the building. There is a small driveway at the front of the building and a large, pleasant garden at the rear. On street parking is restricted to metered areas. The home provides a safe, supportive and stable environment for up to 23 men who are in the second stage of recovery from drug and/or alcohol misuse. It provides a therapeutic programme based on the 12 Step system of recovery, supported by experienced and qualified counsellors. The treatment programme model is behavioural with psychodynamic underpinning. Service users are encouraged to maintain and develop life skills, make new social contacts and develop new interests in the community, whilst exploring the underlying reasons for addiction. The home also provides resettlement advice and help with re-housing, and an aftercare programme for up to one year after leaving the home. Prospective service users are given a Welcome to Thurston House document, and a copy of the most recent inspection report is available in the main lounge. The weekly charge for the residential service is between £688 and £773. Other services provided at Thurston House are charged on a sessional basis. DS0000070373.V357416.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over six and half hours in early January 2008. The inspection methods included discussion with clients and staff; inspection of files and a range of records and policy documents. Clients and staff were sent survey forms so that they could contribute to the inspection process if they wished. The contact details of involved professionals have been requested so that they can be sent survey forms. The CSCI has access to information gathered through notifications from the home. A document called an ‘Annual Quality Assurance Assessment’ (AQAA) was completed by the Manager of the home in advance of the inspection and returned to the inspector. It provides information from the manager about how the home is addressing the National Minimum Standards along with factual information about the operation of the home. All of this information has been taken into account in compiling this report. The Manager, clients and staff facilitated the inspection visit. They were helpful and courteous throughout the process. What the service does well: • • • • • • The information provided to potential clients about the service is comprehensive and clearly describes the restrictions which are part of the therapeutic programme. Clients are supported to work towards their personal goals, including the development of skills and leisure activities. The staff team is well qualified and experienced. They offer skilled and supportive counselling in a way that ensures clients’ rights, dignity and respect. There is support available for clients to maintain family links and friendships, as agreed in their individual plan. The home provides an attractive, homely, comfortable and safe environment, and plentiful and nutritious food There was positive feedback from past and current clients about the services provided at Thurston House. Some people spoke of the compassion they had been shown by staff. All of the people spoken to said that they had benefited from the knowledge, skills and commitment of the staff team. Comments from clients included: • ‘I would heartily recommend the place’. • ‘I am delighted with the treatment I have received here.’ • One person described the group therapy as ‘extremely useful’. • Another said that being a client at Thurston House ‘changed my life’. DS0000070373.V357416.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. DS0000070373.V357416.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 DS0000070373.V357416.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, 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission systems ensure that both the potential client and the home have sufficient information to judge whether the placement will be suitable. EVIDENCE: When a referral is made to Thurston House a range of information is gathered as an initial assessment of the suitability of the placement. Subsequently the potential client is invited to visit the home when an in depth assessment is conducted. If the potential client has come from a primary treatment centre they will be asked to provide a report which will form part of the assessment by Thurston House. An information pack is given to potential clients. The pack includes information about the services available at Thurston House, the weekly time table and the rights and responsibilities of clients. This allows potential clients and the service to have sufficient information to assess whether the placement will meet the person’s needs. The nature of the programme means that a trial stay at the service would be inappropriate. At the assessment visit potential clients are invited to stay for lunch and to look around the house and meet the current clients. Clients are assisted in a number of ways to settle into the home. During the first week of a person’s stay at the home a new client is assigned to another, longer standing, client, known as a ‘senior peer’. The programme requires that DS0000070373.V357416.R01.S.doc Version 5.2 Page 9 when leaving the home the ‘senior peer’ must accompany them. They take responsibility for ensuring that the new person is helped to become familiar with the local area and the range of support mechanisms available both within Thurston House and the local community, and with home and its routines and rules. DS0000070373.V357416.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, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients benefit from their involvement in the care planning process and the day to day operation of the home. There is consideration of risk and its management is incorporated into the policies and procedures of Thurston House. EVIDENCE: Three clients’ files were inspected. They each contained treatment plans which are comprehensive, covering a range of issues including relapse prevention; mental health; self esteem issues; physical health care needs; spirituality; life skills; emotional needs and goals around resettlement in the community. The plans are developed from the assessment and treatment questionnaire which the client completes with their counsellor. The progress of clients towards the identified goals is reviewed as part of the on-going therapeutic process. Placements are reviewed by placing social workers and clients and the home’s staff contribute their views based on the client’s progress. It is an expectation of clients that they actively participate in their treatment programme by attending group therapy sessions, group meetings, individual counselling sessions and completing assignments. DS0000070373.V357416.R01.S.doc Version 5.2 Page 11 Current clients and a member of an ‘after-care’ group spoke of the way in which the programme at Thurston House had helped them to maintain abstinence. The inspector was told by clients that their peer group plays an important part in the recovery programme; one person described the group therapy as ‘extremely useful’ and another said that being a client at Thurston House ‘changed my life’. The planning system is co-ordinated by each client’s named counsellor and recorded both in the file and on a planning board in the office. This is a useful communication tool which ensures that each member of staff is aware of which stage in the placement each client has reached The restrictions on choice and freedom that arise from the recovery programme are explained to service users before admission and reiterated when they take up residence in the home. Clients sign an agreement at the start of their stay confirming that they have read and understand the expectations of the home. Any deviation from the programme must be planned and agreed by the home’s staff and other clients. Clients have opportunities to contribute to the running of the home in a variety of ways. There are regular meetings of the client and staff group, these include daily planning meetings and weekly community meetings. The menu is planned by the client group and each client must perform daily tasks which contribute to the operation of the home, these include cleaning tasks. Risk management is an important part of the work of the home. The issue was discussed with the Manager and a member of staff during the inspection visit. They demonstrated awareness of the issue and how it is incorporated into the working practices of the home. Many aspects of the home’s operation are concerned with managing risk, for example the admission documents make clear that behaviours which may present a risk to clients or staff, or jeopardise clients’ treatment are not permitted. The Manager hopes to develop further the risk management system. All service users sign a release of information form on admission to the home, which specifies exactly to whom information may be released during their stay at the home. Other than this exception, staff are very aware of the sensitivity of information about service users and confidentiality is strictly maintained. All information about service users, including care files, is kept in locked filing cabinets and all offices are kept locked if there are no members of staff present. DS0000070373.V357416.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): 11, 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients benefit from the opportunity to develop life skills and leisure interests as part of the therapeutic programme to maintain their abstinence. Restrictions on clients are made clear to them prior to admission and are part of achieving the aims of the home. A healthy menu which takes into account individual tastes, cultural and nutritional needs is planned with clients. EVIDENCE: The ethos of Thurston House is based on assisting clients to develop their potential and live without dependency on alcohol or drugs. The therapeutic programme includes the development of life skills and leisure interests. The programme is based on the 12-step integrated abstinence based model and includes attendance each week at a minimum of three community based selfhelp fellowship meetings (such as Alcoholics Anonymous and Narcotics Anonymous). Each day clients are required to plan activities for the afternoon when there are no group sessions held in the home. Clients are supported by staff and their peer group with planning their personal activity programmes. Activities DS0000070373.V357416.R01.S.doc Version 5.2 Page 13 which can be pursued in the home include artwork and cookery. This was identified as an area that had improved at the home in recent months, and that clients had benefited from the greater emphasis on encouraging them to have structure to their day. Clients said that they are assisted with planning their future when they leave Thurston House through the input of their counsellor and the Resettlement Worker. Clients told the inspector that they are encouraged to get to know the local area both through participation in local fellowship meetings and through the development of leisure interests. The planning process takes into account cultural and spiritual needs and how they may be met in clients’ leisure activities. The assessment and treatment planning process includes input from the clients on their goals with regard to family relationships and friendships. Clients said that they have been helped to re-establish relationships which are important to them and they have valued this assistance. Counselling sessions involving partners or other family members are available. Clients said that staff who have provided these sessions have been ‘very understanding’. There are rules governing visits to and from the home and these are made clear to clients at the time of their admission. The rules are reasonable and support the aims of the home. The nature of the programme means that there are restrictions on clients in relation to their daily routines. These restrictions are made clear to all clients bat admission. Clients said that the rules and expectations were useful and felt that they contributed to the therapeutic process. An example of this is the restrictions imposed by the community living arrangements in which single rooms are not provided. One person said that this is very important, both in relation to the peer support provided and to the sense of group responsibility which he felt contributes to the therapeutic process. The client group plans the menu each week. The chef attends the menu planning meetings and ensures that the necessary supplies are available. The chef cooks the lunch time meal and clients share the responsibility for the preparation of the evening meal. On the day of the visit to the home there was a choice available for lunch of vegetable curry or beef curry, with rice and cabbage. Fresh fruit was available for dessert. The meal was nutritious and well prepared. Clients and staff praised the chef and said that the meals provided are of a consistently high standard. DS0000070373.V357416.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 good. This judgement has been made using available evidence including a visit to this service. Clients benefit from staff being attentive to their personal and health care needs as detailed in their treatment plans. Medication is well managed, the systems will be strengthened by the development of a procedure for dealing with clients’ refusal to take prescribed medication. EVIDENCE: Clients take responsibility for their own personal care. However staff may be involved in prompting clients in relation to their hygiene and appearance as part of the treatment plan. Service users do their own laundry, including bed linen, keep their own rooms tidy, and also have allocated therapeutic household duties, such as communal cleaning, shopping etc. Going to bed times are flexible but getting up, attendance at meetings and meal times during the week are not negotiable as compliance with the programme is integral to continued residency at the home. Each service users has his own assigned counsellor for the length of stay at the home but can request a change of counsellor if desired. One of the clients spoken with told the inspector that he had requested a change of counsellor, and it had been agreed and implemented by the staff team. Emotional needs are addressed in counselling sessions and at the various groups that are held as part of the programme at the home. Clients said that DS0000070373.V357416.R01.S.doc Version 5.2 Page 15 they had received a great deal of emotional support from the staff and the client group as part of their stay at the home. One person said ‘I am delighted with the treatment I have received here.’ Treatment plans include details of clients’ physical and mental health needs, the role that the home plays in promoting them, and the action that is expected of clients. Clients are encouraged to lead healthy life styles, examples include following a healthy diet and including exercise in clients’ activity plans. When appropriate referrals will be made to specialist health care professionals for assessments. Each client is registered with a local GP on admission. Medication is kept securely. Information is available to staff about the medication that clients are prescribed. In order to be sure that they have information about any possible side effects it would be useful for staff to access patient information leaflets. See recommendation 1. There are systems in place for staff to monitor clients’ compliance with their medication regime. Sometimes clients may refuse medication or fail to collect the prescription from the surgery. The home should establish a procedure to follow in these circumstances. See requirement 1. Training for staff in medication issues has been arranged to take place in February 2008. DS0000070373.V357416.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. This judgement has been made using available evidence including a visit to this service. Complaints and safeguarding adults policies and procedures contribute to the protection of clients. EVIDENCE: The complaints procedure is available to clients in the information provided to clients at the time of their admission. The procedure details the stages of the procedure and the time scales within which a response will be made. Clients were clear that they would raise concerns if they needed to do so and felt confident that they would be dealt with properly. The range of possibilities clients have for discussion with staff means that generally issues of concern are resolved at an early. No complaints have been made over the last year. Clients are informed that any form of discrimination, violent, bullying or intimidating behaviour is unacceptable. Clients and staff confirmed that the ethos of the home is one of support and incidents of this sort are very rare. The home has policies on adult protection, bullying, prevention of abuse and aggression towards staff, and a whistle blowing policy. Staff were clear that they would report concerns to senior staff. The adult protection policy includes details of a range of external organisations with which concerns can be raised. DS0000070373.V357416.R01.S.doc Version 5.2 Page 17 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 excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable, safe and well-maintained environment. Shared spaces complement and supplement service users’ bedrooms and the home is clean and hygienic. EVIDENCE: The home’s premises are suitable for its stated purpose, accessible, safe and well maintained. It meets service users’ individual and collective needs in a comfortable and homely way. The home provides a very attractive and pleasant environment over three floors, with a semi-basement and a large, well kept garden at the rear. It is well situated for access to a large public common, a shopping centre, healthcare and public transport facilities. The building is not wheelchair accessible and cannot be adapted for this due to its Grade II listed building status. It has an entry phone system for increased safety. There are three main communal spaces in the home, the main lounge, the quiet room/lounge and the dining room. The main lounge and the quiet room have good standards of décor, furniture and fittings and are equipped with television and video facilities, a library, pictures and ornamentation. The DS0000070373.V357416.R01.S.doc Version 5.2 Page 18 dining room is large, well decorated and well laid out, facilities for tea/coffee/drinks and snacks, are available at all times. The dining room was found to be clean and hygienic and an attractive and congenial place in which to eat. There is also an art room in the basement, which has an en-suite bathroom and so is also used as the staff sleep-in room at night. The home was found to be clean and hygienic throughout. There is a laundry room next to but separate from the kitchen and dining rooms, which was found to be tidy and well equipped. House keeping and maintenance staff are employed and clients are involved in the cleaning of the home through the inclusion of these duties in the daily programme. A facilities manager is employed by Action on Addiction to manage building maintenance and health and safety issues at the London homes. Service users said that they appreciated the high environmental standards at the home. DS0000070373.V357416.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The clients benefit from a well qualified and competent Recruitment procedures contribute to the protection of clients. EVIDENCE: The care / counselling staff team consists of, in addition to the project manager, three counsellor / project workers, four relief workers and a resettlement worker. The support staff team is made up of a team leader, an admin support worker and the cook. All of the team are well qualified with the counselling and relief workers holding a range of relevant qualifications including addiction counselling and psychotherapy. Administrative and catering staff also hold appropriate qualifications for their area of work. Clients spoke of the skills and sensitivity that the staff bring to their work and how they have benefited from them. One person said of the staff ‘they know what they are doing’ and another commented ‘they are wonderful, very, very understanding.’ The manager confirmed that the recruitment procedure includes appropriate references and checks including enhanced CRB checks. Staff confirmed that these checks were conducted prior to them beginning work at the home. Records were not inspected on this occasion but will be at the next inspection. DS0000070373.V357416.R01.S.doc Version 5.2 Page 20 staff team. The staff confirmed that their induction was appropriate and covered everything that they needed to know to do the job when they began work at the home. Staff are provided with regular supervision. The Client Services Director provides weekly supervision for the whole team and individual supervision is provided by the Manager of Thurston House. Staff confirmed that they are supported to do their work and that there are enough staff to meet the needs of the clients. The training requirements of the staff team are being assessed and will be included in an appraisal system, which is being introduced by Action on Addiction. DS0000070373.V357416.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, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients benefit from a well run home. Quality assurance systems will be strengthened by the completion of reports of visits made on behalf of the Registered Provider. Health and safety systems are well managed. EVIDENCE: The previous Registered Manager of the home left her post in mid 2007. Since then the home has been managed on a part time basis by the Registered Manager of another project run by Action on Addiction. She has begun the process of application to be registered under the Care Standards Act for this home. The post holder is well qualified in psychotherapy and addiction issues and holds relevant management qualifications including the Registered Managers Award. The Client Services Director visits the home each week and this supplements the management cover. When clients leave the home they complete an evaluation form giving their views of the service they received at Thurston House. There is a range of DS0000070373.V357416.R01.S.doc Version 5.2 Page 22 systems in place to ensure that issues including occupancy levels and financial matters are reported to the management team from Action on Addiction. Although senior managers within Action on Addiction have visited the home, generally a written report of the visit is not made. As a result there were no reports of visits made under Regulation 26 of the Care Homes Regulations available for inspection. See requirement 2. Records seen at the inspection visit and information supplied since the inspection showed that health and safety matters are appropriately managed. The fire safety systems have been checked by the London Fire and Emergency Planning Authority (LFEPA) and action they recommended has been taken. Drills are carried out regularly, the most recent was on 24th December 2007, with the previous one approximately six weeks earlier. The fire alarm system is tested within the home regularly. A fire risk assessment, dated May 2007, is in place. Staff received input on fire safety in November 2007 and Fire Marshall training is being investigated. DS0000070373.V357416.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 3 3 X 4 3 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 4 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 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X DS0000070373.V357416.R01.S.doc Version 5.2 Page 24 N/A 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 YA20 Regulation 13(2) Requirement The Registered Person must establish a documented procedure to follow in the event of a client refusing to take prescribed medication. The Registered Person must ensure that unannounced visits to the home are made each month in accordance with Regulation 26. Reports of the visits must be available for inspection. Timescale for action 01/02/08 2. YA39 26 01/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations The Registered Person should ensure that staff have access to patient information leaflets so that they have sufficient information about the medications clients are prescribed. DS0000070373.V357416.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 DS0000070373.V357416.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!