Care Home: Old Rectory (Royal Mencap Society)

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What the care home does well We were impressed by the continued efforts staff are making to involve people in planning and understanding their care. Support plans focus on people`s achievements and abilities. People continue to be involved in making DVD presentations so that they are more fully involved in their formal reviews. People have lots of opportunities to join in activities, inside and out of the home. This includes joining in village activities, having jobs and practicing domestic skills. The staff team have a "can do" attitude and try hard to support people with their choices. Relatives and professionals recognise the efforts that the manager and staff team make to support people with their daily lives and personal goals. The manager has a clear sense of direction and recognises the need to continually improve the service and respond to people`s suggestions, rather than to settle for meeting acceptable standards. What has improved since the last inspection? At the last inspection there were some things the manager needed to do to make the management of medicines safer. She has done these. She and the staff have continued to work hard to develop people`s support plans and to make these accessible to people by using pictures and simple language. What the care home could do better: We have not found anything that the manager needs to do by law. She has her own ideas about what she needs to improve in the next 12 months and has set these out in writing to us. We have suggested that some use might be made of the computer to support people with contacting their families, particularly where families find telephone conversation difficult. To some extent this would also depend on how "computer literate" relatives are, as well as what equipment they have. We have also suggested that the photos and names of regional representatives, in the complaints procedure could be looked at to make sure these are all up to date and people don`t get confused if they need to make contact with one of the senior managers. CARE HOME ADULTS 18-65 Old Rectory (Royal Mencap Society) Somerton Road Winterton On Sea Great Yarmouth Norfolk NR29 4AW Lead Inspector Mrs Judith Last Unannounced Inspection 21st January 2008 03:20 Old Rectory (Royal Mencap Society) DS0000027438.V358348.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 Old Rectory (Royal Mencap Society) DS0000027438.V358348.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. Old Rectory (Royal Mencap Society) DS0000027438.V358348.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Rectory (Royal Mencap Society) Address Somerton Road Winterton On Sea Great Yarmouth Norfolk NR29 4AW 01493 393576 F/P 01493 393576 H2023@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Mrs Gillian Smith Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Old Rectory (Royal Mencap Society) DS0000027438.V358348.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to seven (7) Service Users who have a learning disability may be accommodated. 22nd February 2007 Date of last inspection Brief Description of the Service: The Old Rectory is a large Victorian house surrounded by gardens situated on the outskirts of the village of Winterton-on-Sea. Bedrooms are on the first floor and are single rooms. There are spacious communal rooms on the ground floor. These is no assisted passage to the first floor so people living there need to use the stairs. Fees for the service vary according to dependency from £434 to £588 per week. There are additional charges for hairdressing, chiropody, holidays, transport and personal spending. Residents also pay rent. The manager says that the inspection report is available in the kitchen for residents and staff and discussed with them. Old Rectory (Royal Mencap Society) DS0000027438.V358348.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Our visit was unannounced and lasted almost four hours. We spoke to the manager, one staff member and three people living there. We also looked and listened to what was going on. We got other information from records kept at the home. We spoke to one care manager, had written comments from six relatives and five staff. We got some more information from the Annual Quality Assurance Assessment (AQAA) that the manager had to send to us before we went and from reports of the visits the area manager makes to the home. Care services are judged against outcome groups, which see how well they deliver outcomes for people using the service. We have guidance to help us do this. We have looked at all the information we gathered and the rules, and we believe that the Old Rectory is delivering an excellent service to the people who use it. What the service does well: We were impressed by the continued efforts staff are making to involve people in planning and understanding their care. Support plans focus on people’s achievements and abilities. People continue to be involved in making DVD presentations so that they are more fully involved in their formal reviews. People have lots of opportunities to join in activities, inside and out of the home. This includes joining in village activities, having jobs and practicing domestic skills. The staff team have a “can do” attitude and try hard to support people with their choices. Relatives and professionals recognise the efforts that the manager and staff team make to support people with their daily lives and personal goals. The manager has a clear sense of direction and recognises the need to continually improve the service and respond to people’s suggestions, rather than to settle for meeting acceptable standards. Old Rectory (Royal Mencap Society) DS0000027438.V358348.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. Old Rectory (Royal Mencap Society) DS0000027438.V358348.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 Old Rectory (Royal Mencap Society) DS0000027438.V358348.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): 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective service users could be sure that their needs and wishes would be assessed so the staff had a good idea of what support they needed. EVIDENCE: Each person whose file we saw had an assessment of their needs, showing what they could do and what they needed help with. These also reflected people’s preferences and dislikes. Old Rectory (Royal Mencap Society) DS0000027438.V358348.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, 8 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. The manager and staff team have worked hard to try and develop alternative communication methods to encourage this EVIDENCE: Work has continued to try and restructure care plans so that information is more accessible. Each person whose file we saw had “my support plan” in the front setting out their needs in a variety of areas of daily life, including personal care, domestic skills and social skills and interests. We saw that goals were included on files seen, with pictures to show what these were. Efforts are made to present information in an accessible form. This includes the use of photographs, DVD’s, and simple language. Photos are also used to show what people can do for themselves. One person sat with us to look at their record. They clearly knew what was in it as they leafed through to a particular section of photographs about what Old Rectory (Royal Mencap Society) DS0000027438.V358348.R01.S.doc Version 5.2 Page 10 they liked and that they wanted to show us. One person we asked confirmed they could look at what was in their notes when they wanted. A new staff member has been asked to evaluate all support plans to see whether they feel there is sufficient information and detail to guide them in how they support each person. People told us they were able to make decisions about what they wanted to do. There are risk assessments where these are identified as necessary. . People told us they got to choose things like their food and had been discussing what colour carpet they should have in the lounge. There is recorded evidence of review. One person had their review with the care manager just before we got there. At our last visit we were told that people made DVD’s to show at review showing some of the things they did or had achieved in the last year. The care manager confirmed that this had happened and it encouraged the person to participate in the process. He was very impressed with the efforts of staff to encourage and support this participation. There are risk assessments for activities that people take part in. These are in the process of revision into the new and simpler format adopted by the providers. They reflect where additional support and supervision might be needed and take into account people’s vulnerability. The manager is trying to encourage keyworkers to take more responsibility for the practical updating of these and support plans, so that explains the varying stages these are currently in, as they are “work in progress.” All seven relatives completing comment cards say they always have enough information to help them make decisions. All of them feel that people are given the support and care that they expect and have agreed. Four out of five staff completing comment cards say they always have up to date information, for example from care plans, about people’s support needs. One says they have this “usually”. The staff member on duty had a good understanding of people’s support needs, including what they could do for themselves and what needed either prompting or supervision. We saw people engaged in helping with the domestic routine, hoovering, meal preparation, clearing away. There are pictures of people engaged in these kinds of activities. Old Rectory (Royal Mencap Society) DS0000027438.V358348.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 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service People who use services are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. Overall there is a “can do” attitude with staff encouraging and supporting people with new and different activities and skills. EVIDENCE: We were told about people’s opportunities for employment where they are able. This was confirmed from information on file in both written and photographic form. For example one person works in a supermarket and fast food outlet. Two people continue to be involved in keeping the local bus shelter clean on behalf of the parish council and have recently repainted it. We saw pictures of people making use of local facilities, like the shop and the post office. One person told us they normally plan activities in meetings at Old Rectory (Royal Mencap Society) DS0000027438.V358348.R01.S.doc Version 5.2 Page 12 weekends. The home makes use of a volunteer to help support this process and is going to recruit another. People have joined local village activities like the Scarecrow competition and helping out with ‘Winterton in Bloom’. One relative comments that the person has done more, been more places and socialised far more than they could have done, had they remained with them. One staff member comments that they consider the service to do well in involving people in the village community. One relative commented that the service was good at identifying people’s interests and where possible, arranging for them to pursue these. Another comments in response to the question ‘what do they do well’, that this is “everything!” A staff member told us that there was one person who sometimes went to church and that there was another who enjoyed singing but was adamant that they did not want to go to church to do this. Their choice was respected. The home has made efforts to encourage people to develop skills like shopping for themselves. The provider’s report confirms this and that people are more able to find the things they need in the supermarket independently. We saw photographs showing people shopping and another photo on a different file commenting that the person was waiting for their change. We know from our previous visits, discussions with people living at the home and the AQAA that people are supported with relationships and with breaking up if this is what the person wants. Comment cards from relatives show that five out of six of them feel the service always supports the person to keep in touch with them. The staff member outlined the efforts that they have made to keep in touch with people although relatives are not always responsive. One relative says this happens sometimes but also comments that telephone conversations are difficult due to speech impediments. We have made a recommendation about this. People who can manage, can have keys for their rooms. The routines of the home show flexibility and people feel their privacy is respected. People join in the household routines. People say they like the food. One person writes the menu and we saw past copies of these. We saw a picture of the person writing it out. There are recipe books and lots of photos to help remind people about how to prepare things and to help them make choices. Support plans show pictures of people involved in making meals and preparing their “pack ups” for the next day. We saw one person doing this while we were there. We listened to what was going on at teatime. Meals are normally taken in the kitchen although there are more formal facilities if they are wanted in a separate dining room. Old Rectory (Royal Mencap Society) DS0000027438.V358348.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 and 20. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: We saw people’s personal care needs as met. During our visit people chose whether and when to have baths or showers. One person was assisted with running it. We saw and heard that one person was supported to dry their hair afterwards and asked if they wanted this help, which they accepted. One person has recently been assessed by the occupational therapist to see what aids would make bathing easier. The home is waiting to find out what the person can and will have. Since our last visit the manager has acted to address the requirements we made about medication. One person has their own medicine but does not have access to the full cabinet as before. Staff confirmed training. Records showed no omissions. There was guidance about the use of homely remedies. The manager does spot checks and other staff audit at changes of shift. Old Rectory (Royal Mencap Society) DS0000027438.V358348.R01.S.doc Version 5.2 Page 14 Issues like incorrect or omitted signatures can then be picked up very promptly if they arise. We saw the staff member check both cards and administration records before giving medicines, and encouraging someone to get water to help wash down the tablet. The person also referred to the medication administration record to see if prescribed shampoo was needed that day when they were to assist someone with their personal care. Health action plans have recently been introduced and there has been a meeting with a representative of the learning disability team to discuss their completion, according to the AQAA. The introduction is noted in the provider’s monthly report for December. They are due for completion at the end of this month and are being done, according to that report, at a pace that suits service users. People’s individual files contain pictures of the health centre and doctor that they use so that staff can provide additional support in explaining things if necessary. Relatives make additional comments in their comment cards about the good standard of care and how well they feel people are cared for. Old Rectory (Royal Mencap Society) DS0000027438.V358348.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 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People and their relatives could be confident their concerns would be taken seriously and addressed. There are measures in place to help protect people from exploitation or abuse EVIDENCE: The manager recognises that some people might have difficulty expressing their feelings and fears because of the impact of their learning difficulties. Her AQAA shows that it is considered important by both her and the organisation that staff are vigilant to any changes or signs of concern. Two people we spoke to know who to speak to if they have concerns. From interactions while we were at the home, body language, discussion etc people living at the home showed no signs of distress or anxiety around staff, or reluctance to move freely round the home and in and out of the sleep in room. There is a simplified complaints procedure that is left available to people on the sideboard in the hallway. There is also a cassette tape with it. The procedure has pictures of the organisation’s staff that people can talk to, although recent changes in regional management mean that some of these people have changed should someone wish to raise a concern at that level rather than locally. We have made a recommendation about this. Complaints are looked at as part of the organisation’s quality monitoring processes. Old Rectory (Royal Mencap Society) DS0000027438.V358348.R01.S.doc Version 5.2 Page 16 Five out of six relatives say in their comment cards that they know how to make a complaint if they need to. One of these people says that they have never had to make a complaint. One person says they can’t remember. People feel that, if they have raised a concern, this is dealt with appropriately. Adult protection training figures in the monthly monitoring reports when the provider comments whether any is outstanding. The AQAA shows that one new member of staff was awaiting this training but that all others had it. The manager says she is booked on training for safeguarding vulnerable people, specifically aimed at managers. There is guidance about protection on the noticeboard in the sleep in room, and within organisation policies. The policies for safeguarding people and for whistleblowing were reviewed in December 2006, according to the AQAA. Risk assessments reflect people’s vulnerability. Old Rectory (Royal Mencap Society) DS0000027438.V358348.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 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely, comfortable environment that is safe and clean. EVIDENCE: We did not look at the premises in detail. We did look at stairways, hall, kitchen, one of the bathrooms, dining/sitting room, and rear sitting room. Rooms were clean and homely, with domestic style furniture. New curtains have been put up in the dining room and lounge. There are plans to redecorate three bedrooms. There has been a recent problem that has resulted in damage to the carpet in the dining room. The manager and staff confirm that this is to be replaced and there were carpet samples in the sleep in room for reference. One person told us that they had looked at these to decide what they wanted. There are records to show regular testing of fire detection systems, and maintenance of equipment. Old Rectory (Royal Mencap Society) DS0000027438.V358348.R01.S.doc Version 5.2 Page 18 The manager says that they have recently bought new garden furniture at the suggestion of people living at the home. One relative would like to see the garden area improved. We did not have any concerns about cleanliness. There is infection control guidance available for staff (and protective gloves should they need these). There were no unpleasant odours in the areas we saw. People help to keep their home clean and there is a cleaning rota for staff. One person did some hoovering while we were there and the staff member said they were cleaning their room. One relative comments in their written response that this care home is a “lovely caring environment.” Old Rectory (Royal Mencap Society) DS0000027438.V358348.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, 24 and 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by skilled and competent staff who have a good understanding of their needs. EVIDENCE: The manager had provided contradictory information in the annual quality assurance assessment. However, we clarified this at our visit and were told there are 7 staff, five of whom have NVQ qualifications. One person we spoke to confirmed this and we saw certificates on file. Comment cards from staff say that the induction covered what they needed to know to do the job either mostly or very well. All said that they were being given training that was relevant to their role, helps them understand and meet people’s needs, and keeps them up to date with new ways of working. Old Rectory (Royal Mencap Society) DS0000027438.V358348.R01.S.doc Version 5.2 Page 20 In addition to the organisation’s provision, the manager supports people with additional skills. We saw a package she had put together about encouraging people to engage with activities. She says that she is also trying to train and support people to take more responsibility for updating information about people’s needs, including informal computer training to help with this. The manager says the organisation has developed a new training strategy and that this includes continuous professional development profiles. Those seen are at an early stage. The manager has had training on this and at the point the AQAA was sent to us, the deputy manager had also been booked on training. (We did not check whether this had been completed.) The ongoing work to update and develop these profiles is identified as an improvement the service will be making in the next 12 months. The staff member we spoke to had considerable experience and a good understanding of the needs of people being supported and a commitment to continuing to develop knowledge and skills. One relative comments that staff are “wonderful”. We looked at the recruitment information for the one person who has been taken on since our last visit. This contained the necessary records and checks. Old Rectory (Royal Mencap Society) DS0000027438.V358348.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 and 42 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a well run home and can be confident their views and those of their representatives will be taken into account in developing the home. Their health, safety and welfare is promoted. EVIDENCE: The manager has achieved the necessary qualifications. She attends training that is relevant to the needs of the service users, but also relevant to staff so that she can share knowledge and impart a sense of direction. She has fostered a service that attempts to balance people’s welfare and safety with the aim of increasing people’s opportunities and independence. Old Rectory (Royal Mencap Society) DS0000027438.V358348.R01.S.doc Version 5.2 Page 22 She and the deputy manager have received training that is designed to help them support staff with their development (but understandably are concerned about the demands in their time in doing this based on information in the AQAA). A relative describes the service as now being the “best it has ever been” and that they are “totally satisfied”. The AQAA shows a positive approach to equality and diversity and the manager has contacted the providers about whether they have a presentation she can use with staff on this topic. If there is nothing suitable she has committed herself in the AQAA to adapting the policy and addressing the topic through staff meetings and developing it further in supervision. There are robust systems in place for monitoring service quality. These include surveys and the AQAA shows that responses to the last survey were very positive. There is a continuous improvement plan that provides for updates of issues identified by the manager and providers as needing addressing, as well as any requirements or recommendations arising from our inspection process. Work towards this is monitored regularly with the area manager who makes monthly visits to the service. We have received copies of this information showing the issues arising. These are lengthy reports and the area manager makes two visits – one by appointment to address managerial type issues and to avoid detracting too much from staff input for people living at the home. She makes a second visit which we are told is unannounced, to talk to staff and people living at the home. The manager has made effective use of the AQAA sent to us to set out plans for improvement as well as recognising service achievements. She has responded positively to recommendations and suggestions for improving the service both from the providers and from the Commission. She has incorporated our recommendations in the evaluation of improvements she has made. The plans for continuing to improve the service show that she recognises the need for continuous development and not simply the need to meet minimum standards. We saw health and safety audits and checks. These include arrangements for the testing and maintenance of fire detection systems, extinguishers and lighting. There are also records showing regular servicing of equipment. First aid supplies are monitored and checked regularly. Unlike at our last visit, we had no concerns that identified shortfalls were not promptly addressed. One relative considers the service to be good at health and safety. Old Rectory (Royal Mencap Society) DS0000027438.V358348.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 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 4 3 4 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 4 X X 3 X Old Rectory (Royal Mencap Society) DS0000027438.V358348.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 YA15 Good Practice Recommendations The staff team could consider supporting people to use the computer facilities available with a web cam and e-mail to increase alternative methods of keeping in touch with family members. The photos and names of regional contacts for people to talk to if they have concerns should be updated. This is to help avoid confusion if people or their representatives want to make a complaint. 2. YA22 Old Rectory (Royal Mencap Society) DS0000027438.V358348.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Old Rectory (Royal Mencap Society) DS0000027438.V358348.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. 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