Care Home: Paks Trust Clarence Street

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What the care home does well The service consistently meets the key national minimum standards and addresses identified areas for improvement in a timely manner to ensure positive outcomes for the people who live there. All three houses presented with a very relaxed atmosphere. Staff appeared confident and competent in their roles, and were careful to ensure that peoples diverse needs and wants were met. Peoples care plans reflect their assessed needs. They are detailed and informative ensuring that staff are able to provide appropriate support. Similarly risk assessments enable people to take meaningful risks in a safe manner. People are actively supported to make decisions about their lives both on a daily and more long term basis by staff. People are given support to attend daytime activities of their choosing. These include attendance at local day centres and the PAKS Trust day service as well as participating in their interests, hobbies, chosen college courses, leisure pursuits and holidays. These are varied and reflective of individual likes and dislikes.The involvement of families and friends is important to people, and is encouraged by the home. Clean, tidy, well stocked kitchens enable people to choose from a range of meal options. Support and encouragement with healthy eating is provided. People`s personal care needs vary greatly across the three houses. Staff work with them to ensure that their individual personal care needs are met sensitively and discreetly in line with their assessed needs if requested. Health and wellbeing is also promoted via attendance at routine and more specialized healthcare appointments as necessary. Medication is managed safely on people`s behalf. The home has both a complaints policy and an adult protection policy in place. Staff were aware of their responsibilities regarding adult abuse. All three houses presented as comfortable and clean with no offensive odours apparent. They were decorated nicely with good quality furniture and soft furnishings throughout. Staff numbers in each house were satisfactory. Recruitment procedures are robust and designed to safeguard people. Training undertaken by the staff team ensures that a competent and sufficiently knowledgeable team supports the people who live in the home. Management systems in place are robust. The quality of the service is monitored regularly, and the use of formal systems to test the quality provided ensure that the people living in the home are at the forefront of service development. Health and safety is managed effectively. What has improved since the last inspection? What the care home could do better: No requirements have been made as a result of this inspection. CARE HOME ADULTS 18-65 Paks Trust Clarence Street 17, 18 and 23 Clarence Street Nuneaton Warwickshire CV11 5PT Lead Inspector Justine Poulton Key Unannounced Inspection 24th January 2008 09:00 Paks Trust Clarence Street DS0000004458.V354815.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 Paks Trust Clarence Street DS0000004458.V354815.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. Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Paks Trust Clarence Street Address 17, 18 and 23 Clarence Street Nuneaton Warwickshire CV11 5PT 02476 742201 02476 742201 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) PAKS Trust Mr Robert S Forsyth Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd January 2007 Brief Description of the Service: The registration of Clarence Street covers three separate houses in one street. Two of the houses are for two residents and the other is for one resident. These are terraced houses, each providing a domestic environment as a care home setting. Two of the houses have a communal living room, kitchen and bathroom on the ground floor. The third has the bathroom on the first floor. People’s bedrooms are also on the first floor. All of the houses are staffed 24 hours a day and personal care is offered to some degree in all three houses. The registration is for residents with learning disabilities. PAKS Trust operates this service. The Statement of Purpose for the services provided in one of the houses states that the fees for 2007 / 2008 range from £793.94 to £798.61. The Statements of Purpose for the other two houses were not looked at. Paks Trust Clarence Street DS0000004458.V354815.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 was carried out to establish the outcomes for people living in the home, and to confirm whether they are protected from harm. It took place over two days, with the first day being spent at the organisations office, followed by an evening visiting each of the three homes and meeting with the people who live there. Identified key standards were looked at, along with a review of the organisations progress towards meeting any requirements made at the previous inspection of this service. The pre fieldwork inspection record was completed, as well as a site visit to the home, during which time staff, people living in the home and the manager were spoken with. A completed annual quality assurance assessment was received from the service prior to the inspection along with three completed surveys from relatives. Two people were identified for close examination by reading their care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for service users. Records, policies and procedures were examined and the environment was looked at. All of the people living in the tree houses were at home for all or part of the inspection. The inspector would like to thank the people who live in the houses, the manager and staff for their hospitality and co-operation during the inspection. What the service does well: The service consistently meets the key national minimum standards and addresses identified areas for improvement in a timely manner to ensure positive outcomes for the people who live there. All three houses presented with a very relaxed atmosphere. Staff appeared confident and competent in their roles, and were careful to ensure that peoples diverse needs and wants were met. Peoples care plans reflect their assessed needs. They are detailed and informative ensuring that staff are able to provide appropriate support. Similarly risk assessments enable people to take meaningful risks in a safe manner. People are actively supported to make decisions about their lives both on a daily and more long term basis by staff. People are given support to attend daytime activities of their choosing. These include attendance at local day centres and the PAKS Trust day service as well as participating in their interests, hobbies, chosen college courses, leisure pursuits and holidays. These are varied and reflective of individual likes and dislikes. Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 6 The involvement of families and friends is important to people, and is encouraged by the home. Clean, tidy, well stocked kitchens enable people to choose from a range of meal options. Support and encouragement with healthy eating is provided. People’s personal care needs vary greatly across the three houses. Staff work with them to ensure that their individual personal care needs are met sensitively and discreetly in line with their assessed needs if requested. Health and wellbeing is also promoted via attendance at routine and more specialized healthcare appointments as necessary. Medication is managed safely on people’s behalf. The home has both a complaints policy and an adult protection policy in place. Staff were aware of their responsibilities regarding adult abuse. All three houses presented as comfortable and clean with no offensive odours apparent. They were decorated nicely with good quality furniture and soft furnishings throughout. Staff numbers in each house were satisfactory. Recruitment procedures are robust and designed to safeguard people. Training undertaken by the staff team ensures that a competent and sufficiently knowledgeable team supports the people who live in the home. Management systems in place are robust. The quality of the service is monitored regularly, and the use of formal systems to test the quality provided ensure that the people living in the home are at the forefront of service development. Health and safety is managed effectively. What has improved since the last inspection? The requirements made at the last inspection have been addressed satisfactorily. • • • • • Medication is managed safely with the correct use of codes where necessary, and accurate recording taking place. Risk assessments with regards to hot water temperatures and the surface temperatures of radiators have been carried out and radiator covers fitted where appropriate. A quality monitoring system has been introduced that complements the lifestyle audits that people living in the houses complete on an annual basis. A firewall has been installed in the roof space between one of the houses and the neighbouring terrace. All health and safety tests and checks are up to date. Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 7 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. Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 8 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 Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area was assessed as good at the last inspection; therefore it remains good on this occasion. Suitable systems remain in place to ensure any new people are fully assessed to identify their needs and aspirations so these can be met. This judgement has been made using available evidence. EVIDENCE: The people living in the houses in Clarence Street remain the same as at the previous inspection dated 22nd January 2007. The admissions procedure to any of the three houses also remains the same; therefore key standard 2 was not looked at on this occasion. Paks Trust Clarence Street DS0000004458.V354815.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, 9 Quality in this outcome area is excellent. There is a clear, consistent care planning system in place that provides staff with the information they need to satisfactorily meet peoples needs, and ensures that people are able to make decisions about their lives as appropriate. The people living in this home are supported to take reasonable risks based on effective risk management strategies that are agreed and recorded. This judgement has been made using available evidence including a visit to this service. Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 11 EVIDENCE: Since the last inspection, the manager has spent time working on, updating and rewriting another two person centred plans. The people that these belonged to were chosen for case tracking purposes. Each of these plans contained comprehensive information about the people’s lives including their aspirations, likes, dislikes, personal care needs, healthcare needs, methods of communication, medication and activities / education amongst others. Each element of the care plans looked at had a service aim attached to it, with annual formal review dates, and in house keyworker reviews on a 6 monthly basis. In addition pertinent risk assessments were in place within the plans looked at. These were detailed, and allowed the staff to ensure that the people living in the home weren’t compromised in their choices by ensuring that they were able to take risks in a safe, controlled manner. Risk assessments available included things such as road safety, food allergies, potential burning in sunlight, scalding and going out unaccompanied. Records available confirmed that the risk assessments are reviewed in line with the care plans. Staff and people living in the houses spoken with said that they are supported with making decisions about their lives as much as they are able. One person said that he had chosen the décor of his bedroom, another said that she regularly chose what she wanted to do during the evenings and at the weekends. It was noted that two of the people living in the house had limited communication needs, but that the staff on duty were able to interpret what they were communicating and act on it appropriately. For example, after dinner one person clearly indicated that he wanted to go for a walk, so the staff member on duty undertook to make this happen for him. Paks Trust Clarence Street DS0000004458.V354815.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, 15, 16, 17 Quality in this outcome area is good. People continue to have the opportunity to live ordinary and meaningful lives within the community in which they live. Support to maintain and develop family links and friendships is available. A varied selection of food is available that meets peoples dietary needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All five of the people living in the houses attend day service provisions either at local day centres, PAKS Trust day services or college at various times throughout the week. As part of the inspection the people living in the houses were visited during the evening, after they had returned home from their Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 13 daytime activities. One person said that they had been cooking during the day and had enjoyed the curry that she had cooked for lunch. Activities offered to people during the evenings and at weekends vary from house to house. Information recorded within the support plans of the people case tracked stated that they enjoy activities such as watching local football games, visiting local pubs, going out for meals, attending parties, walking and holidays. Another of the people spoken with said that they enjoy going shopping with staff and away on holiday. Throughout the inspection visit to the houses, staff were seen to encourage people to be as independent as their abilities enabled. In one house the person that lived there provided a guided tour and made a cup of tea, whilst in another people were encouraged to put their dirty plates in the kitchen after dinner. Peoples abilities were fully documented in the support plans looked at, and in conversation staff demonstrated their understanding and knowledge of peoples individual support needs. The manager said in discussion that maintaining contacts with families and friends is very important to the people living in the houses. One person spoke about the frequent visits that they have both to and from their relatives, whilst another was preparing to visit their relatives for the weekend. Information regarding contact with families and friends was recorded within the two support plans looked at. Any visits or contact were also recorded within people’s daily diaries. Each house runs separately, and has it’s own food budget. People spoken with during the inspection said that they like to choose what they want to eat on a daily basis, but do plan a basic menu and shop weekly for their groceries. Dinner observed in one house looked tasty and appetising, and appeared to be enjoyed by both people. In another house the person said that they had chosen sandwiches for tea as they had a cooked meal at lunchtime. All three of the houses had a varied and plentiful stock of fresh, processed and tinned foods available, and records confirmed that staff encourage a healthy nutritious diet. Staff spoken with said that they had undertaken basic food hygiene training. The necessary checks and records to confirm that meals are produced safely and within food hygiene guidelines were available. Information was Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. Peoples support plans ensure that personal support is consistent, reliable and responsive to their needs. People’s healthcare needs are assessed and recognised with evidence of specialist services being readily available to them. Medication policies and procedures ensure that medication is managed safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information recorded within the two support plans looked at contained comprehensive details about peoples individual preferences with regards to their personal care needs. One person spoken with said that they like to have a bath every morning, and staff confirmed that a daily bath or shower at a time pf their choosing is the preferred norm for all of the people living in the houses. Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 15 Recorded evidence was available to confirm that service users are offered routine healthcare appointments such as the dentist, optician and chiropodist at the recommended intervals. Steps have been taken by the manager to obtain the services of an optician that visits people at home to assist with reducing the anxiety one person has about having their eyes tested. Evidence was also available to demonstrate that more specialised healthcare needs are addressed, with records confirming that one person has regular reviews with their psychiatrist whilst another has a two yearly hearing test. Clear and detailed information was also available to staff about how best to support one of the people resident in the houses with a specific health need. An audit of medication was carried out in all three of the houses. It was clear from this that the requirement regarding medication made at the last inspection had been addressed. Medication in all three houses was stored in locked cabinets. It was provided to the service by a local chemist along with medication administration records (MAR). A list of prescribed medication, doses and times which cross-referenced to the MAR charts was recorded within peoples support plans. Medication is booked into the houses by the senior support staff. Examination of the administration records confirmed that where codes had been necessary these had been recorded correctly and the administration of medication had been recorded accurately. Staff spoken to confirmed that they had received training in medication administration. Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. The home has a satisfactory complaints system and can evidence that people’s views are listened to and acted upon. There are policies and procedures in place for the protection of people from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided in the annual quality assurance assessment submitted by the manager prior to this inspection confirms that the service has a complaints policy and procedure in place that was last reviewed in December 2007. Two of the people spoken with during the inspection were able to say how they would voice any concerns or complaints they may have. The staff spoken with were clearly able to identify how those people whose main method of communication was not necessarily verbal, indicated their concerns or unhappiness about something, and respond appropriately. The manager said that the service had not received any complaints since the last inspection. We have not received any complaints either. Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 17 Information provided in the annual quality assurance assessment also confirms that the service has both whistleblowing and protection from abuse policies available, both of which were last reviewed in December 2007. Staff spoken with said that they have received training in safeguarding, which was confirmed by the homes training records. Paks Trust Clarence Street DS0000004458.V354815.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, 30 Quality in this outcome area is good. The appearance of these houses continues to create a comfortable and homely environment for the people living there. The home remains clean and hygienic with policies in place to ensure that the risk of infection is minimal. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registration of Clarence Street covers three separate houses in one street. Two of the houses are for two residents and the other is for one resident. These are terraced houses, each providing a domestic environment as a care home setting. They are within walking distance of Nuneaton town centre as well as local facilities and amenities. Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 19 Two of the houses have a communal living room, kitchen and bathroom on the ground floor. The third has the bathroom on the first floor. People’s bedrooms are also on the first floor. All three of the houses are decorated nicely with good quality furniture and soft furnishings that reflect the personalities of the people that live in them. Staff spoken with in two of the houses said that they were due to be redecorated throughout this year, and would be supporting the people that lived in them to choose paint colours. During the inspection one of the houses was having new double glazing and external doors fitted. The person living in this house commented on how pleased she was with these, and that she was also looking forward to having a new bathroom suite installed this year. All three of the houses were clean and tidy with no offensive odours apparent. Paks Trust Clarence Street DS0000004458.V354815.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, 34, 35 Quality in this outcome area is excellent. People benefit from a well-trained, and enthusiastic staff team who work towards common goals. People are supported and protected by the homes recruitment policy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each of the three houses that make up this service has it’s own dedicated staff team, though there is some movement between the three when covering for holidays or illness. The manager said that they have vacancies across the service that they have recently advertised. An agency that provides staff for a contracted period of time has been used to fill these vacancies to aid consistency for the people living in the home. Information was available to confirm that the agency used recruits staff in accordance with good practice, and provides training information so that the service can be sure that they Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 21 have the right skills to meet the needs of the people living in the houses. The recent recruitment drive resulted in employment offers subject to satisfactory checks and references being made to two people. Examination of the recruitment process confirmed that safe recruitment procedures were undertaken to ensure that people are safeguarded. An application form and proof of identity was available for both people, and records to confirm that two written references, a criminal records bureau check (CRB) and POVA first check had been sent for were also in place. The manager of the service is responsible for coordinating staff training across the organisation. He has a comprehensive training matrix accompanied by staff training records that details exactly who has done what training, when and when refreshers and updates are due. As well as all of the necessary mandatory training such as fire safety, first aid and basic food hygiene, staff have also benefited from training in subjects that include Autism, challenging behaviour, mental health awareness, equality and diversity and epilepsy during the previous twelve months. In addition staff spoken with were pleased to advise that they have completed their NVQ in care II, and one person has completed his NVQ in care III. It was pleasing to note that the organisation places great store on valuing its staff team by providing consistent training to enable them to do their jobs to the best of their abilities. Paks Trust Clarence Street DS0000004458.V354815.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. The leadership, guidance and direction to staff ensures people receive consistent quality care and support. People are consulted about the quality of life within the home. Health and safety is managed appropriately This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home continues to be managed by a suitably qualified and experienced manager who has worked for the organisation for over fifteen years. In discussions with staff it was apparent that the manager is well respected and perceived as open and approachable. Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 23 The home undertakes annual quality assessments via the use of questionnaires that are sent to the people that live there, their relatives and other key stakeholders. This is in addition to the lifestyle audits that the people living in the home complete on an annual basis. Copies of completed questionnaires for 2007 were seen. The responsible person said that once they had all been received they were collated and a report and action plan produced based on the information obtained. Letters are then sent out to relatives and other key stakeholders informing them of the outcome of the quality assessment and how any areas identified as needing improvement are to be addressed. For example, communication was perceived to be poor in the 2007 audit which has been addressed. In addition, the quality of the service provided is monitored via regular staff meetings, regular house meetings and visits by the provider under regulation 26 of the Care Homes Regulations 2001. Evidence was available to demonstrate that the health and safety of people living in the home, staff and visitors is maintained. A sample of health and safety checks was taken, which included fire drills, portable appliance testing, electrical installation testing and fire alarm points, all of which were up to date. In addition the requirements regarding health and safety made at the last inspection had all been addressed. A fire wall has been installed in the roof space between one of the houses and it’s neighbour and risk assessments have been undertaken in respect of hot water and radiator surface temperatures and radiator covers have been put in place where necessary. Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 x 34 3 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 4 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x 3 3 x 3 x x 3 x Paks Trust Clarence Street DS0000004458.V354815.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. 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 Paks Trust Clarence Street DS0000004458.V354815.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Paks Trust Clarence Street DS0000004458.V354815.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!