Care Home: Matson House

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What the care home does well The service completes detailed assessments on prospective admissions and provides good initial information to staff about new service users. The home provides regular training and supports staff to attain the appropriate qualification. The home provides training to the staff in the area of autism so as to ensure there is good awareness around the specific needs of service users who have autistic spectrum disorders. The home maintains good levels of staff supervision. What has improved since the last inspection? Greater consistency over people`s daily routines has been achieved, which has produced better outcomes for service users. Communication with parents and relatives has improved with better consistency of contact and improved sharing of information. The environment of the home has been improved with individual bedrooms being more personalised and maintained to a better standard. The general homeliness and cleanliness has been improved. The relocation of the office facilities enable the manager to be more involved in the daily life of the home. A new sensory area and art room have been developed within the home. There has been a continued decrease in the number of behavioural incidents, with service users appearing to be more settled and relaxed within their environment. The staff team are working better as a team with improved communication and a more consistent approach being employed in the meeting of needs. What the care home could do better: The home needs to improve the Medication administration and eradicate the occasional errors that have occurred. The home needs to continue with their current developments and provide a consistently good service over an extended period of time. CARE HOME ADULTS 18-65 Matson House Matson Lane Matson Gloucester Glos GL4 6ED Lead Inspector Mr Simon Massey Key Unannounced Inspection 16 & 19th November 2007 09:00 th Matson House DS0000016500.V334683.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 Matson House DS0000016500.V334683.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. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Matson House Address Matson Lane Matson Gloucester Glos GL4 6ED 01452 307069 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) Selwyn Care Limited Mrs Jennifer Hands Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. none Date of last inspection 23rd January 2007 Brief Description of the Service: Matson House is part of the care provision offered by Selwyn Care Limited. The home is situated on the outskirts of Gloucester in the Matson area. The organisation provides residential and day care services to adults with Autistic Spectrum disorders and associated behaviours. The home shares the site with the Organisations office, another home and the day care facility. There are spacious grounds around the home, with a lake, garden, fields and a large car park. Matson House has been split into two, Charles House and George House, each occupying a separate floor of the building and each with its own staff team. There are spacious bedrooms and communal areas for use by service users, including separate kitchen, dining and lounge areas for Charles House and George House. There are also separate staff facilities for each of the houses. The home provides transport to enable the residents to access activities outside the home. The home’s Statement of Purpose and Service User Guide provide information as to the services that the home provides. The current fee range for the home begins at £1,320 per week. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days. The Inspector met with the Acting Manager, the organisation’s Group manager, various care staff and the Training Manager. All of the service users were also met by the Inspector. Staff were observed supporting and working with the service users. Records relating to care planning, medication, staff recruitment, health and safety and staff training were examined. An inspection of the environment was also carried out. A number of questionnaires were circulated and returned as part of the inspection process. This was a positive inspection of a service that has undergone a number of changes over the past eighteen months to try and improve the service it delivers. Progress has continued and various improvements were identified during this inspection. What the service does well: What has improved since the last inspection? Greater consistency over people’s daily routines has been achieved, which has produced better outcomes for service users. Communication with parents and relatives has improved with better consistency of contact and improved sharing of information. The environment of the home has been improved with individual bedrooms being more personalised and maintained to a better standard. The general homeliness and cleanliness has been improved. The relocation of the office facilities enable the manager to be more involved in the daily life of the home. A new sensory area and art room have been developed within the home. There has been a continued decrease in the number of behavioural incidents, with service users appearing to be more settled and relaxed within their environment. The staff team are working better as a team with improved communication and a more consistent approach being employed in the meeting of needs. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 6 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. Matson House DS0000016500.V334683.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 Matson House DS0000016500.V334683.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admissions procedure ensures that people’s needs and aspirations are assessed prior to prospective residents moving into the home, and information is then used to form an initial plan of care. The Statement of Purpose provides accurate and accessible information to service users and prospective admissions to the home. EVIDENCE: There have been several admissions to the home over recent months and the documentation and assessments around these people was examined. This showed that a detailed and thorough assessment process was followed with information being collected as to how needs could be met and how the initial plan of care should be implemented. Where appropriate, people are offered a trial visit and overnight stay and prospective service users views about the service they require are actively sought. Two relatives of the new admissions were spoken to and they were positive about how the process had been conducted and the work undertaken by the home to ensure the transition was successful. The new service users were observed being supported by staff and appeared settled and positive in their new home. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed care plans ensure that the service user’s needs are documented and guidance is available to staff. The home takes action to encourage service users to make choices and supports them to take appropriate risks. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 10 EVIDENCE: A selection of care plans were examined. The home has continued to improve the system it uses with increased documentation being kept on all aspects of the care and support being provided. Care plans are regularly reviewed and updated and the information is person centred, providing clear guidance for staff on how the service is to be delivered. Increased staff understanding of the needs of autistic behaviours has improved the ability to support choice and decision making by the service users. This is reflected in the individual programmes and routines that have been developed. All risk assessments seen were up to date and had been regularly reviewed. Staff interviewed demonstrated a good awareness of the role of risk assessing as means of supporting independence and increasing choice. There was evidence of good recording, which showed the staff’s ability to observe and record in a non-judgemental style, increasing the knowledge of a service user’s needs. Staff spoken to were also able to show that they had a good understanding of the care plans and the various guidelines that were in place for the different service users. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 11 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, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service have been given increased opportunities to take part in a variety of activities in the community and in the day centre. Service users benefit from a more structured approach towards the development and implementation of their care plans. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 12 EVIDENCE: A sample of the daily and weekly routines being followed were examined, as well as a sample of trips into the community over the previous few months. This showed that people are offered individual activities that generally meet their assessed needs. There is a commitment from the staff team to follow the structured routines and to follow the timescales in order to minimise anxiety and improve the consistency of the service delivered. There has been a clear improvement in this aspect of service delivery since the previous inspection. Questionnaires returned from relatives, and interviews conducted during the inspection, showed that the home has improved its communication and liaison with service user’s families. People were positive about the frequency of contact and the sharing of information was considered appropriate. One relative commented upon the positive response they always received when phoning the home to ask for any information about their son’s activities. People also said they were kept informed of any health issues or concerns and asked to contribute to the reviewing of the care and support that was being delivered. Relatives expressed confidence in the service that was being provided and several commented upon the improvement in communication, the condition of the accommodation and the consistency of the approach of the staff. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 13 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. People’s personal and healthcare needs are met, promoting their dignity and wellbeing. The home’s medication procedures and staff training are satisfactory but errors by staff could compromise the safety of the service users. EVIDENCE: Guidance is provided to staff on how personal care is to be delivered and staff were observed treating service users with respect and dignity. There is evidence that people’s health needs are being monitored and clear records are kept of appointments and any ensuing outcomes. People have accessed any specialist services that have been required and the home has liaised appropriately with the Community Learning Disabilities Team. Records are kept of individual weights and action is taken to provide guidance in terms of diet and eating habits. All service users are having Health Action Plans developed. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 14 There was evidence that staff are aware of the difficulties in monitoring some health issues due to the needs of the service users and the home has taken action to investigate concerns thoroughly when the source of problems has not been obvious. The Commission has received several notifications relating to medication errors that have been made in the home over the past few months and these issues have been discussed with the home. The home has also had an inspection from the Commission’s Pharmacy Inspector. The home has taken action in respect of the requirements and recommendations that have been made and as part of this inspection process produced a written statement in relation to the actions being taken to improve the performance in this area. This has included reviewing training, administering procedures, location of medication storage and, when appropriate, disciplinary action being taken. There has been an improvement in respect of the frequency of errors over the past two months and it is essential that this is continued. The home have been transparent about the problem it is addressing and proactive in attempting to improve the service provided in respect of medication administration. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 15 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. The home has satisfactory arrangements and procedures in place for the protection of service users and provides a safe environment for service users in which they are respected and treated with dignity. EVIDENCE: There is complaints policy in place and action has been taken by the home to ensure that all relatives and people involved with the service are aware of this and how to access it. Relatives spoken to were aware of how to make a complaint or raise a concern, and stated they would be confident of doing this if the need arose. Improved training around communication and the use of various visual aids have increased the ability of the staff to seek the views of the service users and also encourage people to make decisions about their daily lives. There appeared in general to be a more relaxed atmosphere within the home during this inspection, with service users appearing comfortable and relaxed in their environment, and also in their interactions with the staff team. Staff commented upon this change and it was noted that there has been very few incidents regarded as challenging behaviour, that have had to be managed by the staff team. This is as result of a variety of changes and the lack of the need for physical intervention reflects well upon the home, and provides evidence that service users are protected and in a safe environment. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 16 Staff have received training in Adult Protection issues and in interview staff were able to demonstrate an understanding of the various issues. Staff interviewed, and responses in questionnaires, showed that people were aware of how to make a complaint or raise a concern, and that there was confidence that issues would be listened to and if necessary action taken. Reference to the training being provided in the management of behaviours and potential physical intervention is contained within the Staffing Standards section of the report. Matson House DS0000016500.V334683.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 good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home that is well maintained and decorated throughout and provides a comfortable and reasonably homely environment. Service users are supported and encouraged to personalise their living space and efforts are made to involve them in the decisions relating to redecoration of the home as far as their abilities allow. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 18 EVIDENCE: An inspection of the environment was carried out and various improvements to the quality of the accommodation were seen. All of the individual bedrooms have now been decorated and all were personalised according to taste and needs. Service users spoken to, or observed, expressed their satisfaction with their rooms and people were seen enjoying the privacy of their own space. Efforts have been made to improve the homely quality of the building with the addition of various drapes, lighter colours and some new fixtures and pictures. An upstairs room has been converted into a sensory area and another into an art room. Efforts have been made to improve the main lounge in the downstairs of the building and the plans for updating the kitchen were explained during the inspection. Staff commented that maintenance issues were reported and that action was usually taken fairly quickly. One service user has a self-contained ground floor flat and this has been recently extended to better meet their needs. There have previously been several recorded incidents of challenging behaviour relating to this person but these have significantly reduced. Staff commented that the improved living space was a contributing factor in this. The main hallway has had an office fitted and also an area for the care staff to meet and complete paperwork. This area is much more central to the main activities of the home and people commented that they thought this had been a positive development for the service users as well as the staff team. This also helps the management to be more in involved in the daily events in the home. The home has now employed a cleaner and the cleaning responsibilities are shared with this person and the care staff. Some service users have a limited involvement in the cleaning of their rooms, as far as their abilities allow. The home appeared to be clean and hygienic throughout. The outside of the home provides a secure area for the service users, though people are supervised when outside of the building. One person has their own private garden area, which meets their need to be outside but avoid conflict with other people. One small part of the home had an unpleasant aroma and the cause of this was explained during the inspection. Steps are being to taken to improve this. It was generally observed that the environment has been improved in an attempt to provide more homely accommodation and to overcome some of the practical difficulties in having such large accommodation spread over three floors. Matson House DS0000016500.V334683.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. Service users are supported by a staff team that is well trained, relates well to them and has a positive approach to their care and support. Formal supervision of staff, maintenance of staffing levels and clear guidance in meeting needs has produced increased opportunities and improved outcomes for service users. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 20 EVIDENCE: The records relating to staff recruitment were examined and found to be in order. Information relating to the most recently recruited staff were seen and these contained all the required information and showed that all the necessary checks had been completed. New staff were very positive about the induction process and support they received during their initial stage of employment. Staff stated that they thought the training was “excellent” and “really good”, and was appropriate to the role they were undertaking and that it had been delivered well. There was a comment that the “shadowing” period could have been longer and some staff were a little unclear about the mentoring process but overall the training and induction is of excellent quality and is a very positive aspect of the service provided by the home. All staff spoken to, and responses in questionnaires, demonstrated good staff understanding of the needs of people within the autistic spectrum disorder and an understanding of the skills required to work successfully in the service. New and established staff were positive about the team working dynamics and several people commented upon the improvement in this aspect of working in the home. People said they felt well supported by the Acting Manager and that improved communication within the team had improved the working atmosphere, as well as the outcomes for service users. Feedback from relatives was very positive about the efforts of the staff and their approach to meeting the needs of the service users. One relative commented that staff were “always friendly and welcoming” and another commented that the staff were “ well informed about the service users”. Another commented on the improvement in communication with the home and that they were very pleased that they now received regular updates and information about the care their son was receiving. There was also evidence that staff support service users who are able, to have regular communication with their relatives. People are supported to visit their relatives, with help being provided with transport where appropriate. The service has a full time training manager and they stated that all staff were up to date with the required training and it is clear that this is closely monitored. Additional training is provided, such as autism awareness and communication training. After their six-month probation period all staff are expected to undertake NVQ training. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 21 The rota showed that staffing levels are being maintained with the occasional use of agency staff but this is now down to much lower levels than at previous inspections. All service users who are being funded for one to one care were being provided with this level of service at the time of the inspection. Staff confirmed that these levels were being maintained except in exceptional circumstances. One agency worker arrived to undertake a shift during the inspection and they were provided with a clear induction, guidance as what tasks they could undertake and also what was not expected of them in relation to some service users. This was good practice and helped ensure that people’s needs were not compromised. Staff were positive about their supervision, which they have been receiving regularly and people said they felt supported by the Acting Manager and the Provider’s Group Manager who has a close involvement in the running of the home. There have been regular staff meetings and the minutes of these show a variety of issues being discussed and attempts being made to improve understanding of certain issues and improve outcomes for services users. The home has stopped using the accredited training it was accessing in respect of managing challenging behaviours and has now started delivering its own, as yet unaccredited training, titled Understanding the Severn Senses. This training does not incorporate any physical intervention techniques, though it was explained that there are staff in the service that can deliver this, if required. The training does teach breakaway and make safe techniques. Whilst the Inspector accepts that it is commendable to have a policy of “no physical intervention” there have been occasions over the past twelve months when this has been necessary, and there will be times when prevention of injury to service users or members of the public, may only be prevented if intervention occurs. Staff could conceivably find themselves in situations, which as they are not trained for, could put them and service users at risk. It would be a little late in these circumstances to provide this training after a need has been identified. Many of the initial assessments identify the potential for challenging and aggressive behaviours and whilst good practice and understanding may eliminate the majority of risk, it seems that there is a certain element of risk attached to eliminating this aspect of the training altogether. This aspect of care needs to be closely monitored by the Provider and is an area that will closely inspected at future inspections. The Training Manager estimated that it could take twelve months for the training to be successfully accredited, but there is no guarantee of this. This is a long period for a specialised unit to operate without training that is fully approved and accredited and, in the Inspectors view, it would have been better for the training to be have been introduce on a gradual basis whilst ensuring that accredited provision was still available. Matson House DS0000016500.V334683.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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home that is well managed and organised and committed to providing high quality care and support. Systems are in place that help to monitor and improve the quality of the service. There are a range of measures in operation that help to protect service users’ health and safety. EVIDENCE: The home has had an Acting Manager for nearly twelve months, due to the long-term absence of the Registered Manager. There was evidence throughout this inspection that excellent levels of leadership and direction have been provided and a clear commitment to improving the quality of care provided and the outcomes for service users. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 23 The Acting Manager is enthusiastic and committed to their role and has demonstrated an understanding of the improvements that were required, in order to improve outcomes for service users. There have been clear improvements in the performance of the staff team, both individually and as a team, with better understanding being evident of the complex needs of the service users. There appears to be a calmer and more relaxed atmosphere within the home, whilst a positive level of control is maintained in a professional and caring manner by the staff team. This is reflected in the manner, observed by the Inspector, in which staff respond to service users in a confident but non aggressive manner when meeting needs. There appears to be greater awareness of how behaviours can escalate when not responded to appropriately. The management have been proactive in challenging poor practice and additional supervision and mentoring has been provided when it was thought necessary.There has also been reduction in overall sickness levels and whilst there was a high turnover of staff at the beginning of the year the home now appears to be in a more stable period. There are various Quality Assurance processes in place. The Group Manager has undertaken and completed regular Regulation 26 Inspections, and copies have been forwarded to the Commission. Following this inspection this will be no longer required. These visits have occurred at night and at weekends, as well as during normal working hours. They have produced action points for the home and have been followed up by the Acting Manager. The service has an annual plan of improvement that covers various aspects of service delivery. This is informed by the observations of the Group Manager, feedback from Quality Assurance surveys and feedback from the staff team. There are also regular management meetings with other managers who work on the same site and work in other services run by the same Provider. The Acting Manager has received supervision from the Group Manager, who has been involved in the running of the home and has supported the Acting Manager to implement and make changes to improve outcomes for the service users. All fire safety checks and maintenance have been completed, work that is coordinated by the maintenance team that cover the whole site run by the Provider. Regular health and safety audits are completed every month and any required actions reported to the Manager. Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 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 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 x Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 25 yes 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 home must ensure that medication is correctly administered Timescale for action 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office 4th Floor Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Matson House DS0000016500.V334683.R01.S.doc Version 5.2 Page 27 - 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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