Care Home: Manor Road (96)

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What the care home does well There are clear care plans in place to provide staff with the information they need to meet the needs of the people who use the service. The people who use the service are assisted to make decisions about their lives in accordance with their abilities. They take part in appropriate social and educational activities and have opportunities for personal development. The daily routines and the arrangements for promoting family contact support the people who use the service. Varied meals that suit individual tastes are provided in homely surroundings. The people who use the service receive the appropriate personal support in the way they prefer and require. The systems in place for managing complaints and adult protection matters ensure that the wellbeing of the people who use the service is safeguarded. A comfortable and pleasant home environment is provided. Observations of staff indicated that they are caring and respectful towards the people who use the service. The staff spoken with were very knowledgeable about their needs and appeared to have a very good relationship with them. The people who use the service appeared relaxed and content with the staff. The people who use the service said they like living at the home. Some comments made were "I like it here." "I like the staff." "I`m happy here, the food is nice."Staff said they "they are happy working at the home", "the care and the service given is excellent" and the "home is run in the interests of the people who live there." A relative spoken with was happy with the care provided at the home. Staff had a good understanding of the home`s policies and procedures and the general operation of the home. Staff spoken with said the manager is very supportive. What has improved since the last inspection? Since the last visit there have been a number of improvements to the physical appearance of the home. The bedrooms and communal areas have been redecorated, new flooring provided in the kitchen and a new dining room table and chairs made available. These improvements enhance the appearance of the home and make it a more pleasant environment for the people who use the service. There was evidence at this visit that all risk assessments are being reviewed on a regular basis. Evidence that the emergency lighting system is regularly serviced was also available. What the care home could do better: Recommendations have been made at this inspection which are in general around making records better. Recommendations are seen as good practice for the Registered Provider/s to consider carrying out. The vacancies for permanent support workers need to be filled to ensure consistency in the staffing arrangements at the home. Steps have been taken to address this. CARE HOME ADULTS 18-65 Manor Road (96) 96 Manor Road Wallasey Wirral CH44 1BZ Lead Inspector Beate Field Unannounced Inspection 20th May 2008 11:00 Manor Road (96) DS0000035511.V362623.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 Manor Road (96) DS0000035511.V362623.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. Manor Road (96) DS0000035511.V362623.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Road (96) Address 96 Manor Road Wallasey Wirral CH44 1BZ 0151 639 0401 F/P 0151 639 0401 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) Metropolitan Borough of Wirral Mrs Lynda Nelson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Manor Road (96) DS0000035511.V362623.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 Date of last inspection 22nd May 2006 Brief Description of the Service: Manor Road is owned by Wirral Metropolitan Borough Council and is registered to accommodate 4 adults with a learning disability. Manor Road is a two storey, mid-terraced property, situated on a main road. On the ground floor there is a lounge, dining room, kitchen, bathroom and a laundry room. On the first floor there is a bathroom, a separate toilet and four single bedrooms. The home has a garden, which has seating areas. Access to the front and back of the home is via a step. Parking is available on the main road. Manor Road is located within a half-mile of Liscard town centre. There is easy access to a bus service from the home. At the time of the inspection, the people who use the service were contributing between £65.20 and £102.90 towards the cost of the service depending on their state benefit entitlements. A copy of the statement of purpose would be made available to relatives and social workers prior to admission. The service users guide to the home would be made available before a person comes to live at the home and the content discussed with them to ensure their understanding. Manor Road (96) DS0000035511.V362623.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 star. This means the people who use this service experience good quality outcomes. This inspection took place over 5 hours and is based on a visit to the home, information received about the service since the last inspection and by an Annual Quality Assurance Assessment (AQAA) completed by the manager. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the manager. A tour of the home was undertaken. The inspector spoke with the people who use the service and a relative. The inspector spoke with staff and made observations of staff delivering care to the people who use the service. What the service does well: There are clear care plans in place to provide staff with the information they need to meet the needs of the people who use the service. The people who use the service are assisted to make decisions about their lives in accordance with their abilities. They take part in appropriate social and educational activities and have opportunities for personal development. The daily routines and the arrangements for promoting family contact support the people who use the service. Varied meals that suit individual tastes are provided in homely surroundings. The people who use the service receive the appropriate personal support in the way they prefer and require. The systems in place for managing complaints and adult protection matters ensure that the wellbeing of the people who use the service is safeguarded. A comfortable and pleasant home environment is provided. Observations of staff indicated that they are caring and respectful towards the people who use the service. The staff spoken with were very knowledgeable about their needs and appeared to have a very good relationship with them. The people who use the service appeared relaxed and content with the staff. The people who use the service said they like living at the home. Some comments made were “I like it here.” “I like the staff.” “I’m happy here, the food is nice.” Manor Road (96) DS0000035511.V362623.R01.S.doc Version 5.2 Page 6 Staff said they “they are happy working at the home”, “the care and the service given is excellent” and the “home is run in the interests of the people who live there.” A relative spoken with was happy with the care provided at the home. Staff had a good understanding of the home’s policies and procedures and the general operation of the home. Staff spoken with said the manager is very supportive. 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. Manor Road (96) DS0000035511.V362623.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 Manor Road (96) DS0000035511.V362623.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 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The contracts could better support the interests of the people who use the service. EVIDENCE: A service user guide and a statement of purpose are available that provide information about the services provided at the home. Advice was given to the manager about updating these documents in accordance with the changes to the Care Homes Regulations 2001. The service user guide should also be written to better reflect the needs of the people who may read it. The people who use the service have lived there for over 10 years. The assessment paperwork that is available and the assessment process described by the manager at previous inspections, would ensure that a full assessment of a persons needs would be made before they are offered a service. The statement of purpose indicates that a person considering using the service would be able to visit the home to meet the current people using the service and staff before making a decision as to whether the home is suitable for them. Manor Road (96) DS0000035511.V362623.R01.S.doc Version 5.2 Page 9 A sample of contracts/statement of terms and conditions were seen and provide the information that is needed. Information relating to the changes of fees payable since the contracts were drawn up was available. The contracts/statement of terms and conditions have been made available in a format that is more suited to the needs of the people who use the service. Relatives/advocates have not been involved in the completion of the contracts. As indicated in previous inspections, it would be good practice for an appropriate individual, who is independent of Wirral Borough Council, to be involved in supporting the people who use the service when drawing up the contract/statement of terms and conditions. Manor Road (96) DS0000035511.V362623.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflect the assessed and changing needs of the people who use the service, which means that staff have access to the information they require to appropriately support them. EVIDENCE: Information in the care plans is detailed and easy to understand. The care plans seen had had a recent review. Each aspect of the persons needs, including, their cultural and religious background are taken into account when care planning. The staff spoken to could clearly describe the needs of the people who use the service and how to meet them. The manager reported that were possible the relatives of the people who use the service are consulted prior to the review of the care plans. A relative Manor Road (96) DS0000035511.V362623.R01.S.doc Version 5.2 Page 11 spoken with confirmed that they are kept up to date about their relatives needs and asked their opinion of the service being given. The people who use the service do not have named social workers, however, the purchasers of the service should be asked to provide their views on whether the service is continuing to meet the needs of the people who live there. At present a weekly record is made of the well being of the people who use the service with more frequent entries being made were there is a significant event such as an illness. It is recommended that a daily record be made as this provides clearer evidence of the day-to-day well being of the people who use the service and the action staff have taken to meet their daily needs. The records, observations and a discussion with the people who use the service indicated that they are assisted to make decisions about their lives in accordance with their abilities. Records of the likes and dislikes and preferences around daily living, such as what time they like to get up and the activities they enjoy assists in making sure that the people who use the service have their choices respected. Records show that the people who use the service are asked their opinion about the day to day running of the home at weekly house meetings and through questionnaires. In addition the staff spoken to said that they frequently ask the people who use the service for their views. Records show that the people who use the service take part in the running of the home as their needs allow. The people who use the service who were spoken to said that they are asked about what meals they would like to eat, where they would like to go to on holiday and what activities they would like to do. The people who use the service said they had recently chosen the colour that they would like their bedrooms decorated. The people who use the service said they like living at the home. Some comments made were “I like it here.” “I like the staff.” “I’m happy here, the food is nice.” A sample of risk assessments seen indicated that the people who use the service have their needs assessed and their need for independence is balanced with any risks to their wellbeing. All risk assessments seen had been regularly reviewed. All records are held securely at the service. Staff are made aware of the procedures around protecting the confidentiality of the people who use the service during their induction. Manor Road (96) DS0000035511.V362623.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service are able to take part in activities that provide opportunities for their social and personal development. The daily routines and the arrangements for promoting family contact support the wellbeing of the people who use the service. EVIDENCE: Records show and the people who use the service said that they attend adult training centres, go to college and take part in a range of leisure activities. The people who use the service said that they enjoy these activities. Staff spoken to said that the activities have been chosen by the people who use the service with staff support. Manor Road (96) DS0000035511.V362623.R01.S.doc Version 5.2 Page 13 The records show that people who use the service take part in community life. The people who use the service are supported to use local facilities such as shops and public transport. The people who use the service spoken with said that they like to go out in the local area. Although there are sufficient activities available or the people who use the service, there are currently staff vacancies at the home, which can lead to limited opportunities to have 1:1 activities or trips out during the evenings. This is being actively addressed by the manager. The people who use the service, staff and records indicated that family relationships are promoted. A relative spoken with confirmed this also. The people who use the service have a holiday each year. A destination is decided on by the people who use the service during the weekly meetings that are held at the home. The people who use the service also enjoy short breaks away form the home and day trips. Discussions with staff, records and observations confirmed that the home’s routines are flexible as much as possible. The people who use the service said they like a “lie in” and can “watch television until late” if they wish. The records inspected indicated the support the people who use the service need in their daily lives in order to make choices and encourage independence. The people who use the service are involved in the planning of meals. During the visit one person prepared the pudding to follow the evening meal with staff support. The care plans detail likes and dislikes and any dietary requirements. The people who use the service reported that they enjoy the food provided. Meals are planned on a four weekly basis. A menu is maintained. The menus indicated that a variety of different foods are provided. A record of foods provided is also contained in the communication book. It would be good practice for this information to be recorded in each persons individual records. Manor Road (96) DS0000035511.V362623.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 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The personal care needs of the people who use the service are well met and they are safeguarded by the home’s procedures and policies for the management of medication. EVIDENCE: Manor Road (96) DS0000035511.V362623.R01.S.doc Version 5.2 Page 15 The care plans examined indicate the support the people who use the service require around their personal care. Individual preferences regarding personal and health care support are recorded in the care plan. Care plans and risk assessments are regularly reviewed. The people who use the service are provided with support around their personal care by staff of the same gender. The key worker system promotes continuity of care for the people who use the service. Observations indicated that staff promote the dignity of the people who use the service. Staff interviewed were aware of the support needs of the people who use the service. The care plans give detailed information about specific health care needs. Thorough records show that the people who use the service are supported to attend healthcare appointments and have access to health care services when they are needed. The outcome of any appointments and the follow up action required is clearly recorded. The medication procedure was seen and gives clear guidance to staff. All staff have received training in the home’s medication procedure. In addition all staff have completed a training course in the safe handling of medication. The manager makes an assessment of the competence of staff before they are can administer medication. A sample of medication administration records and corresponding medication were inspected and were correctly maintained. Medication is stored securely. Manor Road (96) DS0000035511.V362623.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff training and policies and procedures are in place to ensure that the views of the people who use the service are listened to. The practices at the home provide the people who use the service with protection from abuse. EVIDENCE: There is a complaint procedure that is suited to the needs of the people who use the service. The people who use the service said that if they were unhappy they would speak to a member of staff or the manager. Information is available to enable a complaint to be made on behalf of a person who uses the service or by an advocate. The complaint procedure describes the stages of the complaint and that the complainant will get a formal answer to their complaint within a maximum of 21 days if the complaint cannot be resolved informally. Staff interviewed were aware of the content of the complaint procedure and how to respond to complaints. There have been no complaints to the service or to the CSCI since the last key inspection of the service. There are appropriate procedures in place to protect vulnerable adults from abuse. The manager and all staff have had training around the protection of vulnerable adults. The staff interviewed were aware of how to respond appropriately to an allegation of abuse. Manor Road (96) DS0000035511.V362623.R01.S.doc Version 5.2 Page 17 The home manages the personal allowance for one person. The records of this were examined. These records were appropriately maintained with systems in place to keep a check on the accuracy of the records. Manor Road (96) DS0000035511.V362623.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service live in a safe, comfortable and homely environment. EVIDENCE: Manor Road (96) DS0000035511.V362623.R01.S.doc Version 5.2 Page 19 Since the last inspection the home has been redecorated throughout. New dining room and some bedroom furniture has been made available. New flooring has been made available in the kitchen. It continues to be recommended that the pipes in the downstairs bathroom be boxed in, as this will improve the appearance of the bathroom. The manager has reported that these pipes do not become hot. The bedrooms are personalised and reflect the interests and lifestyles of the people using the service. All bedrooms have been redecorated since the last visit to the service in a colour scheme chosen by the people using the service. The communal areas of the home contain some photographs of the people who use the service. The manager said that more could be displayed and that she will talk to the people who use the service about this. There are displays around the home of pottery made by the people who use the service. The people who use the service are able to lock their bedroom doors in accordance with a risk assessment. There are sufficient toilet and bathroom facilities available. There is a toilet available on both floors of the home. There is a bathroom on the first floor and a downstairs shower room. All bedrooms are on the first floor. The people who use the service are supported to use the shower room so that it promotes their dignity. Records showed that regular checks are undertaken of the electrical wiring and appliances, gas safety and of fire safety equipment to ensure the wellbeing of the people who use the service. A tour of the home showed that the home was clean. It is clear that the staff are working hard to ensure good standards of cleanliness are maintained throughout the home. There are procedures for staff to refer to about hygiene. Manor Road (96) DS0000035511.V362623.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): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff to meet the needs of the people who use the service and the staff are competent to meet their needs. EVIDENCE: The staffing rota shows that there are sufficient staff to meet the needs of the people who use the service. During the day there are between one and two staff available. There is one member of staff available most evenings. Extra staff are made available for planned activities. Having one member of staff limits the opportunity for the people who use the service to undertake unplanned activities or separate activities. The manager reported, that there are currently 3 staff vacancies and that when additional staff are employed there will be two staff available more evenings and at the weekends. Wirral Metropolitan Borough Council is currently advertising for support staff for the home. Manor Road (96) DS0000035511.V362623.R01.S.doc Version 5.2 Page 21 Bank (employed by Wirral Metropolitan Borough Council) and agency staff cover staff vacancies and absences. The same bank and agency staff are employed who know the people who use the service and how the home works. No new staff have been employed since the last inspection. Two staff have left the service. There are satisfactory recruitment procedures and policies available to ensure that the people who use the service would be supported and protected by the home’s recruitment processes. Evidence that the agency staff are suitable to work at the home was available. There was evidence of appropriate recruitment checks by the agency and of suitable training. Agency staff shadow staff who are permanent and who know the service well and receive an induction before working alone at the home. Training records indicated and staff spoken with said that training is provided to ensure the people who use the service are being cared for properly and that their needs are being met in accordance with current good practice. 2 of the current staff team have an NVQ in care of adults with a learning disability and 2 permanent members of staff are working towards this qualification. The induction and foundation training programmes have been developed in accordance with the National Training Organisation training targets. Training around equal opportunities is provided to staff. Staff have also attended training around promoting the rights of the people who use the service. Staff spoken with said they are well supported by the manager and have access to sufficient training opportunities. They said “they are happy working at the home”, “the care and the service given is excellent” and the “home is run in the interests of the people who live there.” Manor Road (96) DS0000035511.V362623.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, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service live in a well run home that operates in their best interests. EVIDENCE: The manager has the qualifications, skills and experience suitable for her role. The manager has been in post for 8 years and has completed an NVQ level 4 in care and management. Prior to this the manager worked as a deputy manager for 6 years in a similar setting. Records indicate that the manager has undertaken periodic training to maintain and update her knowledge, skills and competence while managing the home. Manor Road (96) DS0000035511.V362623.R01.S.doc Version 5.2 Page 23 There are a range of quality assurance systems in place. An annual development plan is produced each year. Feedback is sought from the people who use the service at house meetings and through individual discussion with their key workers. A questionnaire is sent to relatives and the people who use the service. Records showed that 3 relatives had returned questionnaires and that they are made to feel welcome at the home, they are supported to keep in touch with their relatives, kept informed about important issues and that the people who use the service can make choices about their daily lives. Some comments made were “ My relative is well cared for and always seems happy. They have a full and happy life thanks to the staff at Manor Road.” “I know my relative is in safe hands and with staff that love her as much as I do. They benefit greatly from being at the home and I appreciate all they do for her.” “My relative is well looked after.” Staff meetings are held. Staff supervision is provided. The representative of the registered provider makes visits to the home on a monthly basis in accordance with Regulation 26 of the Care Homes Regulations 2001. A copy of these reports are forwarded to the CSCI. There is evidence that a review takes place of policies and procedures and that these are updated accordingly. Both staff and training records indicated that staff receive appropriate training in safe working practices. Manor Road (96) DS0000035511.V362623.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 2 2 3 3 X 4 3 5 2 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 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 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 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 3 X X 3 X Manor Road (96) DS0000035511.V362623.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations A review of the statement of purpose and service user guide is to take place to ensure that the changes made to The Care Homes Regulations 2001 are covered and that the service user guide better reflects the needs of the people who use the service. A representative of the people who use the service should be involved in the completion of service user agreements/contracts. It is recommended that a daily record be made of the wellbeing of the people using the service and the action staff have taken to meet their daily needs. It is recommended that two members of staff be deployed on more evening shifts as having one member of staff limits the opportunity for the people who use the service to DS0000035511.V362623.R01.S.doc Version 5.2 Page 26 2. YA5 3. YA7 4. YA32 Manor Road (96) undertake unplanned or separate activities. Manor Road (96) DS0000035511.V362623.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG 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. 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