Care Home: Shirley Gardens, 43

What the care home does well The service provides residents with the opportunity to make decisions and choices about their daily life. The staff team work well together and have an awareness of how to support residents with mental health needs. Feedback from residents and staff was positive and reflects the changes made in the home over the past year. What has improved since the last inspection? There have been significant improvements to this home since the last inspection. Prospective residents are assessed prior to moving into the home. Risk assessments were detailed and recorded how to minimise identified risks. Medication systems had improved and were more robust. Furniture had been purchased for the living room. Recruitment checks and staff training had improved. The Registered Manager had developed a quality review report outlining the work the home had carried out over the past twelve months. Systems were in place to monitor more closely when residents go out into the community without staff. What the care home could do better: Staffing levels need to be monitored to ensure there are two members of staff working on each shift. Information regarding the recruitment checks carried out on relief/casual staff and external agency staff need to be available in the home. CARE HOME ADULTS 18-65 Shirley Gardens, 43 Ealing London W7 3PT Lead Inspector Sarah Middleton Key Unannounced Inspection 21st April 2008 09:20 Shirley Gardens, 43 DS0000027714.V362093.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 Shirley Gardens, 43 DS0000027714.V362093.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. Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shirley Gardens, 43 Address Ealing London W7 3PT 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) 020 8810 0431 020 8567 1704 hm43shirley@ealing.org.uk www.supportforliving.org.uk Support for Living Yaw Duodu Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0), Physical disability (0), Physical disability over 65 years of age (0) Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th April 2007 Brief Description of the Service: 43 Shirley Gardens is a facility for seven people with mental health needs. The home is also registered for people with physical disabilities but it is not wheelchair accessible and there is no lift or special equipment. Support for Living manages the home and the building is owned by a Housing Association, who is responsible for repairs and maintenance. The home is a three-storey house, located in a cul-de-sac in a residential area of Hanwell, close to the Uxbridge Road. Adjoining the home is a block of flats for eleven tenants for whom an outreach service is provided by a separate staff team. Some of the flats can be accessed from the homes office but since the 1st April 2008 this service is completely separate to the registered care home. The home has seven single bedrooms, located over the three floors, one of which is on the ground floor. The ground floor also has two small lounges, a dining room, kitchen, laundry, sleeping-in room and office. The first and second floor each have three bedrooms. There are three bathrooms with toilets, one on each floor, and two additional separate toilets. There is a staff shower in the sleeping-in room. The large car park is accessed from Shirley Gardens and there is a small garden area to the front, with access to the Uxbridge Road. The staff team consists of the Registered Manager, Deputy Manager and support workers. There is one domestic worker. There is a minimum of two staff on each shift and one member of staff sleeps in at night. There is no waking night cover. Fees range are £963.74 per person per week, this includes contributions from Social Services and the residents living in the home. Shirley Gardens, 43 DS0000027714.V362093.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 was an unannounced inspection carried out between 9.20am-4.30pm. We gathered information about the home through a variety of ways, including postal surveys, talking with residents and staff and looking at relevant documentation, such as a support plan, staff training records and maintenance records. The Registered Manager had completed a new Annual Quality Assurance Assessment and this assisted with the inspection process. There were no resident vacancies and one staff vacancy had been filled subject to the required recruitment checks on this person. The Registered Manager had implemented many positive changes over the year and this was evident throughout the inspection visit. The aims and objectives of the home are being considered and a potential change might be that it becomes a rehabilitation home to support residents to gain skills and confidence before moving onto more independent accommodation. All of the thirteen previous requirements were met and two new requirements were made. All key National Minimum Standards were assessed. What the service does well: The service provides residents with the opportunity to make decisions and choices about their daily life. The staff team work well together and have an awareness of how to support residents with mental health needs. Feedback from residents and staff was positive and reflects the changes made in the home over the past year. Shirley Gardens, 43 DS0000027714.V362093.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. Shirley Gardens, 43 DS0000027714.V362093.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 Shirley Gardens, 43 DS0000027714.V362093.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed prior to moving into the home. EVIDENCE: Evidence was seen that the home has a pre-admission assessment and this was used to assess the needs of the most recently admitted resident. This document was detailed and covered a range of areas, such as mental and physical health needs. The assessment process was carried out over several days and the Registered Manager confirmed he had met with the prospective resident. The Registered Manager had introduced an induction pack for new residents to give them information about the home. We spoke with the new resident who confirmed they had visited the home and made an informed decision to move into the home. Shirley Gardens, 43 DS0000027714.V362093.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. Support plans outline residents needs and how these are to be met. Residents are encouraged to make every day decisions about their lives. Residents are able to take risks and these are assessed. EVIDENCE: The home is in the process of updating the support plan format. We viewed a blank version and this covered ten key areas of a resident’s life, such as physical and mental health needs, family and relationships and personal care needs. The hope is that this new document will be introduced in the near future. We viewed a current support plan that the Registered Manager had developed for the interim period. This covered, as above, the main aspects of the resident’s life and recorded how staff needed to support the resident. Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 10 Evidence was seen that the resident had been consulted and had contributed to the support plan. Each month the keyworker, who completes the support plan, meets with the resident and this is recorded along with a monthly summary of the resident’s life. Generally the residents have a full review of their needs with the community mental health team. This is either held every six months or on an annual basis. Samples of daily records were also seen. The Registered Manager had updated the form used and this encouraged staff to record specific relevant details about the resident each day. The Registered Manager is in the process of assessing, along with other professionals, a resident’s placement, as their specific needs are changing. The Registered Manager is conscious that the home might need to support the resident to move to more suitable accommodation. We were satisfied that the resident’s best interests would be acknowledged and considered throughout the assessment process. Both staff and residents spoken with confirmed that residents were encouraged to make daily decisions. Where possible residents manage their own finances and are supported to budget their personal money. Small samples of risk assessments were viewed. These outlined the identified risk, indicators of the risk and ways to minimise the risk. Residents are encouraged to comment on the risks staff have assessed and recorded. One risk assessment recorded that a resident did not agree with the identified risk. It is seen as good practice to include resident’s views on support plans and risk assessments and to acknowledge where there might be a difference of opinion. Shirley Gardens, 43 DS0000027714.V362093.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. Residents are encouraged to engage in daily activities and tasks both in the home and in the community. Residents are supported to maintain social relationships. Residents’ rights are recognised. Overall the meal provision aims to provide healthy meals for the residents. Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 12 EVIDENCE: Currently one resident attends a local centre and takes part twice a week in various activities. Other residents are supported and encouraged to carry out daily chores and activities. The majority of the residents can and do go out into the community without staff. Residents use public transport and access different places, such as the local shops and the pub. Staff are aware of those residents who need support and motivation to go out of the home. The Registered Manager and staff recognise the residents need motivating and patience when organising certain activities or appointments. Often residents will change their minds and decline taking part in an activity. Staff spoken with described that residents over the past year have taken part in more things around the home and that although these changes are small, they are significant. Day trips are organised for those interested and holidays can be arranged if this meets the needs of the resident. Those residents who have family contact continue to maintain relationships and visitors are able to visit the home or take the resident out. Those residents asked confirmed they are able to spend time alone or with others. Residents are discouraged from spending long periods of time in their bedrooms. Monthly resident meetings take place and all residents are encouraged to attend and contribute to the meeting. Samples of menus were viewed and generally the meals were varied and provided some nutrition for the residents. Overall residents said they were happy with the meals. Staff aim to provide fresh fruit and vegetables, although this remains an area that is monitored as most of the residents do not want to eat this type of food. Residents choose an evening meal they want to eat and usually staff cook this main meal. Staff spoken with described how they had been preparing more culturally appropriate food for one of the residents. Residents prepare their own breakfast and lunch or eat out in the community. The home has purchased new fridges, freezers and cookers and the hope is that the kitchen will be updated in the near future. Food that had been opened was covered and dated. Shirley Gardens, 43 DS0000027714.V362093.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. Residents receive personal care support as and when needed. Residents’ health needs are recorded and were being met. Robust medication systems protect the welfare of the residents. EVIDENCE: The majority of the residents manage their own personal care. At times some might need prompting and reminding to wash their clothes and maintain good personal hygiene. Residents are free to chose when they get up and go to bed. Where needed, referrals to specialist professionals are carried out, such as the Occupational Therapist. Residents’ health needs are recorded on their support plan. Residents are supported to attend health appointments, and it is recognised that at times appointments have to be changed if the resident feels unable or unwilling to attend an appointment. Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 14 The Registered Manager said that where possible residents are supported, when they are anxious about an appointment, by a member of staff they trust. We viewed medical appointment forms that are used to record when a resident has seen a health professional, along with the outcome of the visit. This enables staff to monitor any changes in health needs. We were informed that staff have an active role in supporting resident’s to maintain good health and this was evidenced with regards to one resident who’s general health had improved over the past year. Samples of medication systems were viewed. Daily checks are carried out on medication. This includes counting those medicines that are in boxes or bottles. The home stores medication in a metal locked cabinet and the majority of medication is stored in a sealed blister pack. There were no controlled drugs in the home at the time of the inspection. It was noted that a resident had been given some Paracetamol on the 18/4/08, but that it had been recorded both on the correct resident’s Medication Administration record and on another resident’s records. This was discussed with the member of staff and the Registered Manager. Staff receive training on administering medication and shadow existing staff when they first join the staff team. The Registered Manager agreed to ensure all staff had up to date training on this subject. All other medicines and records checked were correct on the day of the inspection. The Annual Quality Assurance Assessment stated that there was a resource file with information on the main medicines administered in the home. Evidence was seen that this was in place in the office of the home. This file outlined details on the medication usually administered in the home and the possible side effects. Shirley Gardens, 43 DS0000027714.V362093.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. Residents are able to voice their concerns and their views are listened to and acted on. Systems were in place to protect residents from abuse. EVIDENCE: Those residents asked and those who completed the postal surveys said they knew who to speak with if they had a concern or issue in the home. The home had not received any complaints over the past twelve months. The complaints file was viewed showing how a concern would be recorded to ensure it is followed up appropriately. There have been no adult abuse referrals or investigations. The home has the Local Authority’s policy and procedure on adult abuse. Staff receive information and training on this subject. The residents’ personal money was counted on the day of the inspection. This is counted daily and all financial transactions are recorded. Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 16 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, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall residents live in a pleasant and comfortable home. There are sufficient shared spaces for the residents. The home was clean and free from offensive odours. EVIDENCE: The Annual Quality Assurance Assessment stated that new furniture had been purchased for the living room. This was seen and is now a much brighter and pleasant place to sit in. The Registered Manager was aware that a small area of the floor in this room was damaged and will address this shortfall. A resident showed their bedroom and this was clean and tidy, although as residents now smoke in their bedroom, the paintwork was becoming discoloured. Although this resident said they were happy with the décor if their room. As stated earlier, the Registered Manager is hopeful that the kitchen will be updated later in the year. Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 17 Residents can smoke in their bedrooms, the designated smoking room or outside. Although the door to the smoking room is kept closed, the smell of smoke could still be noticed in the living room. This issue was discussed with the Service Manager and Registered Manager, as this matter needs to be resolved. Appropriate outside shelter should be provided for those residents wanting to go outside to smoke. The home has a cleaner five days a week. The expectation is that residents keep their bedrooms clean and tidy. Residents are supported to also carry out laundry tasks. The odour on the second floor had been addressed and there were no unpleasant odours at the time of the inspection. Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent staff team supports the resident’s. Residents would benefit from sufficient numbers of staff working in the home. In order to protect residents, recruitment procedures need to be followed for all staff. The training programme meets the needs of the staff and consequently the residents. EVIDENCE: The majority of staff have obtained an NVQ level 2 or 3. The recently appointed Deputy Manager will have the opportunity to study for an NVQ level 4. Staff spoken with were committed to providing positive support and encouragement for the residents. Residents commented positively on the support they receive from staff. Many of the members of staff have several years experience working with people with mental health needs. Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 19 A shift plan is completed each day to inform and guide staff as to what needs to occur in the home each day. The rota was viewed and this showed that on some days during the week there has only been one member of staff working on shift. The Service Manager and Registered Manager acknowledged that this was not ideal. Often this had been happening when a member of staff was on holiday or sick. We were informed that the home should have two members of staff working on each shift and a requirement was made for this to be addressed. A new member of staff is due to join the staff team once the recruitment checks have all been completed. This should then ease some of the staffing difficulties. In addition, the Registered Manager will look to increase the casual/bank staff that work in the home covering vacant hours. Those staff asked said although it was not ideal working alone there is an on call system in place for staff to contact a senior member of staff for advice and support. Staff meetings take place on a regular basis and all staff are encouraged to attend. Staff employment files were viewed. The home holds information regarding recruitment checks on a form. This outlines that the members of staff have provided two satisfactory references, medical clearance has been obtained, and a Criminal Record Bureau check has been carried out. The two files seen had these forms along with photographs completed correctly. Details on casual/bank staff and external agency staff were not available in the home. The Registered Manager had begun obtaining some information on casual staff, but he is aware that the usual form used, as noted above, needs to be used for the casual staff working in the home. It is a requirement that evidence must be available that appropriate recruitment checks have been carried out on all members of staff working in the home. Evidence of the training attended was viewed. The Registered Manager had devised an overall training plan that showed the courses and training that staff had attended. Staff receive training on relevant subjects and had received some training on mental health issues. The Service Manager confirmed that he had requested further training on this subject to the training department, as they organise training opportunities. The Registered Manager is aware of those staff needing to have their training updated and this had been booked for the near future. Information had been given to staff on the new Mental Capacity Act 2005 and the Registered Manager intends to consider how to implement this act in everyday practice. Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 20 One member of staff spoken with confirmed they had received a detailed induction, outlining the main aspects of working in the home and that this had been helpful when getting to know the home and their role within the home. The Registered Manager has introduced an in-house induction for new staff. This provides specific details on working in the home, such as planning the shifts, administering medication and health and safety issues. Any formal induction should be relevant to working in a mental health home and not relating to learning disabilities, as this had been the common practice in the past. Both the Service Manager and the Registered Manager are keen for new staff to receive training that is solely relevant to the staff’s roles and responsibilities when working in a home for people with primarily mental health needs. Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ benefit from a well managed home. Residents can be confident that their views are listened to and the home is reviewed throughout the year. Residents are protected by robust health and safety procedures. Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Registered Manager has been in post for just over a year. In this time, as mentioned throughout the report, there have been significant changes made for the benefit of the residents and staff. Staff agreed that residents are doing more things for themselves and that overall staff were positive about having direction and leadership from the Registered Manager. Residents are asked to complete surveys, so that their views on the home are obtained and where possible acted on. Monthly Regulation 26 reports are completed and copies are made available. The Registered Manager had introduced a short annual quality review report. This provided an overall view of the home and the past twelve months. This was in the communal hall and available for residents to see. We were pleased to see that the home continuously looks at ways to make improvements and recognises where there are shortfalls. Maintenance records were viewed. The Registered Manager had completed an environmental risk assessment. This document was detailed and relevant to the home. Other checks were up to date, such as Gas Safety record, testing for Legionella and Portable Appliance Test. Fire drills had been held on a regular basis and at different times. A fire risk assessment had been completed. The home records when a maintenance job has been referred so that it can be monitored when jobs are fixed. Overall the health and safety of the people living in the home was assessed, considered and recorded. Shirley Gardens, 43 DS0000027714.V362093.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 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 2 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 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA33 Regulation 18(1)(a) Requirement The staffing levels must be monitored, to ensure the safety of the residents is considered and their welfare is protected. Timescale for action 19/05/08 2. YA34 19(1)(b)(i) To protect residents, 19/05/08 evidence of recruitment checks need to be available on all staff working in the home, including relief/casual or agency staff. 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 YA28 Good Practice Recommendations It is recommended for the home to have a designated outside covered smoking area for the residents. Shirley Gardens, 43 DS0000027714.V362093.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Shirley Gardens, 43 DS0000027714.V362093.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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