Care Home: Southview Close

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What the care home does well This home cares for people with complex needs and residents are looked after well. Staff remain committed to providing a high standard of care to all residents. Staff reported that they felt communication between staff members was good and that they continued to work well as a team. Southview provides a homely and safe environment for people to live in. People who use the service make choices about their day to day life including meals, activities outings and holidays. Community liaison with health and social care professionals is also good and the health and social needs of the residents are well met. What has improved since the last inspection? The environment has been improved upon by redecorating various areas and providing new furniture which is more appropriate to the particular lifestyle and needs of the residents. The garden has been landscaped and is more accessible to all residents. A new case reviewing system has been introduced which places the resident at the centre of their review. Some of the areas stated in the AQAA where the home has improved includes improved relationships with purchasing authorities, training of a communication specialist in the service and E learning in values and Person Centred Modules What the care home could do better: No requirements were made following this inspection. The home has identified areas within the AQAA where they intend to focus on over the next 12 months. CARE HOME ADULTS 18-65 Southview Close 1 Southview Close Rectory Lane Tooting London SW17 9TU Lead Inspector Davina McLaverty Key Unannounced Inspection 21st October 2008 11:00 Southview Close DS0000010226.V364576.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 Southview Close DS0000010226.V364576.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. Southview Close DS0000010226.V364576.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southview Close Address 1 Southview Close Rectory Lane Tooting London SW17 9TU 020 8682 3312 020 8682 3422 vivienne.donald@macintyrecharity.org www.macintyrecharity.org MacIntyre Care 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) Miss Vivienne Zoe Donald Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (3), Physical disability (12), of places Physical disability over 65 years of age (2) Southview Close DS0000010226.V364576.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one named service user who has a mental disorder under 65 years of age. 20th June 2006 Annual Service Review :21st September 2007 Date of last inspection Brief Description of the Service: Southview Close is a home for twelve adults with learning disabilities, some of whom also have a physical disability. The property is purpose built and has been adapted for use by service users with wheelchairs. The home is on two floors and is divided into four flats, each with their own kitchen /dining room, lounge, toilet and bathroom. All bedrooms are single occupancy, with four bedrooms having ensuite facilities. Shared facilities include the garden. The home is situated in a quiet residential area near Amen Corner, Tooting and is within easy reach of shops and community facilities. The area is well served by public transport and the home has the use of an adapted minibus, The home has five allocated parking spaces. Street parking is restricted. Further information concerning the service can be found on the organisations website at www.macintyre-care.org. At the time of this inspection the manager of the home reported that the fees per year range from £54,000 - £58,000. Additional charges are made for some outings and holidays. Southview Close DS0000010226.V364576.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 stars. This means the people who use this service experience good outcomes. The inspection included an unannounced visit to the service on the 21st October 2008. We met six residents, two prospective residents, the manager, and six staff members. We also looked at a number of records, which included four resident’s files, care plans, health and safety records as well as the environment. In addition, the inspection took account of information received about the service since its last inspection. We also contacted the residents who live at the home, their relatives and staff who work in the home. We asked them to complete surveys about their experiences. Surveys were received from one staff member, and six residents, all of whom whose relatives had completed their surveys on their behalf due to level of disability of their relative who is unable to complete their own survey. Comments received were very positive and where relevant are reflected in the report. We asked the manager to complete an Annual Quality Assurance Assessment (AQAA), which is a self assessment of the service and is also referred to in the report and helped us to form some of the judgements made. Two residents spoken to on the day of the inspection stated that they were happy and satisfied with the care and support provided. Comments included “it’s nice here”, “the staff are supported and help me to do things I want to do”. What the service does well: This home cares for people with complex needs and residents are looked after well. Staff remain committed to providing a high standard of care to all residents. Staff reported that they felt communication between staff members was good and that they continued to work well as a team. Southview provides a homely and safe environment for people to live in. People who use the service make choices about their day to day life including meals, activities outings and holidays. Community liaison with health and social care professionals is also good and the health and social needs of the residents are well met. Southview Close DS0000010226.V364576.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. Southview Close DS0000010226.V364576.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 Southview Close DS0000010226.V364576.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,& 4 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home understands the importance of having sufficient information when choosing a care home and have developed a Statement of Purpose and Service User Guide to help people make a decision about moving in. Admissions are not made until a full needs assessment has been made. Prospective residents are given the opportunity to spend time in the home. EVIDENCE: The Statement of Purpose includes information about the aims and objectives of the service, the accommodation available, staffing level, the admission process and activities both in the home and in the local community. A Service Users Guide has been developed which provides information about the service, the key work system and how to make a complaint. One resident spoken to said that they had enough information to help them when they moved into Southview. Residents are assessed by support staff prior to moving into Southview and a clear record is made. Residents are able to visit for meals and to meet other people living in the home before a decision is made as to whether they will Southview Close DS0000010226.V364576.R01.S.doc Version 5.2 Page 9 move in. Prospective residents can stay overnight /weekends if they choose. This was seen on the day of the inspection when one prospective resident was staying for two nights. Another resident visited for the afternoon to help them decide if this was the place that they wanted to live. Staff were observed to be very welcoming, patient and helpful with both residents and their families. One survey received stated “We visited the home many times then had a weekend then a week’s trial before we decided it was the right place for him.” “He is treated very well”, “the home is always very fresh and clean including toilets and beds always first class” Detailed assessments were seen on the file of one of the prospective resident whose file was looked at. We saw assessments by placing care managers and staff from the service, which include details of the support and assistance individuals need. Multi disciplinary professional input was also evident as well as the views of the persons advocate. The AQAA states that the home is planning to develop the Statement of Purpose and Service User Guide further by producing them in a more accessible format for service users and where possible to involve service users. Southview Close DS0000010226.V364576.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 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People who use the service are involved in developing person centred plans. Staff understand the importance of people being encouraged and supported to take control of their lives and make their own decisions and choices. People are able to take risks so that they can live their lives to the full and do the things that they want to do. EVIDENCE: Four care plans were examined at this inspection. The home uses a person centred plan, which is specific to resident’s individual needs. Staff reported that work on care plans is on going. We saw information covering assessments of what people can do and the areas they need support and assistance from staff. Person centred plans are evident with the resident, where able, being encouraged to identify some goals they would like to achieve. Evidence of the resident’s involvement was also seen. The manager Southview Close DS0000010226.V364576.R01.S.doc Version 5.2 Page 11 stated that pictures are used where residents are not able to communicate verbally. Guidelines were available detailing the resident’s daily routines. These guidelines enable new staff to understand how to deliver care to residents. Information in the AQAA states that since the last inspection the organisation has appointed a communication advisor, as well as training of a communication specialist within each service. The format of resident’s reviews had changed to be more person centred. These reviews will be more informal and whilst they will take longer, they will focus on what is important to the person and will be much more person centred with more sharing of information and documenting in a way that the person can understand. We saw a copy of the one of the resident’s review which had used this new format which was very positive and clearly from the documentation the resident had been at the centre of their meeting. In discussion with the staff member she stated that the review was less intimidating for the person involved, encouraged them to participate more and was positive for the person as the meeting pulled out their strengths and what they had achieved. The service operates a key worker system, which allows staff to work on an individual basis with people who use the service. One person spoken to confirmed that they meet regularly with their key worker and do things they want to do. There were written risk assessments which showed that staff, have thought about the risks people take. Files examined identified individual risk assessments e.g. mobility, finance, medication. as well as general risk assessments e.g. premises, equipment, tasks. People are encouraged to be as independent as the wish and to take risks. There are regular meetings for the people who live at the home, where they are told about any changes that may affect them. They also have the opportunity to raise any issues they feel are relevant to communal living. Notes following these meetings were seen. Comments received from family members were very positive about the home and include “my relative is very happy in the house they get the best of care from the staff”, and “as far as I know they are treated very well” Southview Close DS0000010226.V364576.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service has a strong commitment to enabling residents to develop their skills, including social, emotional, communication and independent living skills. Individuals are supported to identify their goals and work to achieve them. They are also supported to stay in contact with relatives and friends. EVIDENCE: The senior support worker stated that the majority of the residents attend local day centres five days a week. However, a couple of residents attend part of the week and have one to one support, or attend classes at an adult education centre or participate in projects such as theatre and gardening. Two of the older residents do not attend regular day care, staff will take them out or involve them in- house activities e.g. puzzles, games, TV or listening to music. One resident attends an art club in the evening, others may go swimming or to Southview Close DS0000010226.V364576.R01.S.doc Version 5.2 Page 13 the gym. A couple of residents has an aromatherapist visit them weekly. Staff stated that regular trips take place to the cinema, shopping, and parks and out for meals or to the pub. Evidence of these trips was seen in the care plans examined. Staff support and provide opportunities to residents to develop social, emotional, communication and independent living skills. Currently residents who are able are involved in domestic and household chores. Residents have an individualised programme of activities for the week and staff said that they make sure that there is time for individual activities, such as shopping, going to the park, having a meal out. This helps residents to have a positive relationship with their support workers; key worker activities are also arranged. Residents are consulted about any religious or spiritual needs they may have. A couple of residents attend church regularly. Support is given with medical and other health appointments when needed. Residents are able to maintain contact with their family and friends. This is achieved either by the resident visiting or visitors coming to the home. Survey comments from relatives included “my daughter makes decisions about what to do each day. She has a varied programme which includes day centre and 1 to 1 support where she goes swimming shopping etc. She loves going out. “Her days and evenings are planned so she has some choices” and my daughter comes home every other Sunday but is always in a hurry to go back to her flat.” “The carers are excellent. Communication is good” and “my daughter is lucky to have a nice place to live, when she was at home I worried about her future when I could not care for her. Thank God those worries are now gone.” Another stated that “I am completely happy with the care my relative receives”. As stated earlier the home is working with a communication advisor to improve how staff can engage and communicate more with the people living there. The home has its own specially adapted mini bus, which allows trips further a field to be planned for the weekends. The bus enables staff to be spontaneous and take service users out with minimum planning. Holidays are encouraged and supported. The menu showed that residents are offered a varied range of foods and staff reported that most meals are prepared from fresh. Separate meals are usually cooked in each kitchenette. Where residents are able they are encouraged and supported to get involved in the meal preparation. Special diets can be catered for. One resident is muslin and staff purchase halal meat, which is stored and cooked separately. Southview Close DS0000010226.V364576.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 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home supports people to maintain good health with any changes in peoples needs being addressed. People’s medication is appropriately managed. EVIDENCE: As stated earlier the majority of residents are non-verbal or find it difficult to discuss their needs in detail. Personal care needs however, were seen to be recorded within guidelines evidencing that resident’s physical and emotional health needs are met. Personal support is responsive to the varied and individual needs and preferences. Staff confirmed that assistance is given with personal hygiene and privacy is respected. Staff were observed to treat residents with respect and were see to be very patient with residents with more severe communication difficulties. Staff are aware of privacy and dignity issues and speak with individuals in private. One person spoken to said that the need for their privacy was respected and that staff would knock on their bedrooms door and wait to be invited in before entering. Southview Close DS0000010226.V364576.R01.S.doc Version 5.2 Page 15 Support plans make sure that individual healthcare needs are addressed with support being given as required to visit the GP, dentist, optician and other health appointments. There are good links with other professionals in the health service e.g. occupational therapists and physiotherapists and residents on the whole have the aids and equipment they need to maintain their independence and support them and staff in daily living. We saw records of GP, hospital and other health related appointments in case files. Staff monitor people’s weight on a regular basis and currently help individuals with healthy eating. Medication in two units were looked at and found to be appropriately managed with good systems in place. A new medication policy is in place. The organisation is currently revising how training is delivered and is moving towards an in house service which will overseen by the manager who will receive external training three yearly and refresher courses annually. The inspector saw copies of the work books to be used which were very comprehensive. Only staff who have received training in the administration of medication administers medication. Southview Close DS0000010226.V364576.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 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place for the management of complaints. The manager makes sure that all staff is aware of their responsibilities regarding the Safeguarding of Vulnerable Adults. Training is provided for staff in the safeguarding of Vulnerable Adults. EVIDENCE: The complaint procedure continues to be evident in the home. No formal complaints have been received since the last inspection. Three staff spoken to were aware of the Protection of Vulnerable adult’s procedures as well as whistle blowing. A copy of Wandsworth Protecting Vulnerable Adults Procedure was seen in the home. Staff receive training in Safeguarding of Vulnerable adults and staff working at the service know when incidents need external input and who to refer the incident to. We were informed that there have been no changes to supporting residents with their finances. Staff support the majority of residents to manage their money. Receipts are kept of each transactions and money checked at each handover. Southview Close DS0000010226.V364576.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, 25,26,27,28, & 30 People who use this service receive excellent quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home has been recently refurbished and is comfortable, clean with a good standard of furniture fittings EVIDENCE: The home is divided into four units, two on each floor. All four units, which are quite different, were homely in appearance taking into account resident’s individual needs. Redecoration of many areas in the units and new furniture in communal areas as well as in several of the resident’s bedrooms has enhanced the environment immensely. New furniture and fittings were solid in design but homely in appearance. The living environment is appropriate for the particular lifestyle Southview Close DS0000010226.V364576.R01.S.doc Version 5.2 Page 18 and needs of the residents and is homely, clean, safe and comfortable, well maintained and reflects the individuality of the people using the service. The service has been creative in how it involves people in decision –making and positively encourages people with a limited capacity to be as fully involved as possible. The bathrooms and toilets are fitted with appropriate aids and adaptations to meet the needs of the people who use the service e.g. hoists, parker bath, raised toilet seats and frames are available to individual residents as required. Extensive work had also taken place in the garden, making it accessible to all residents as well as safe by raising the fences which have deterred local children using it as a “cut through”. Flowers had also been planted; many were still in bloom which made a very pleasant environment for residents and staff to use during the warmer months. Staff spoke of the summer bar-b-cue which had been a great success and was well attended by residents, their families, friends and staff. The manager in the homes AQAA states that the home is planning over the next 12 months to continue with its maintenance plan both in the home and garden where a swing will be put in. The home was seen to be clean and tidy on the day of the inspection. Southview Close DS0000010226.V364576.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,& 35 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The staff team support each other and share skills and knowledge to provide a good service to people. Staff roles and responsibilities are clearly defined. Good staff recruitment practices are in place, ensuring people who use the service are protected. Staff have access to training appropriate to their roles. EVIDENCE: Staffing levels in the home vary depending on the needs of the people living there. A minimum of three staff are always on shift across two units during core hours of the waking day, with one staff sleeping in and a waking night. These staff levels were seen to be sufficient to meet people’s needs. However, in view of the needs of a prospective resident staffing levels have increased to enable the persons needs to be fully met and the person has a 1 to 1 worker during the waking day and at night a further waking night staff is on shift. This will be reviewed once the person has settled in. Staff spoken to also confirmed that there were sufficient staff on duty each shift. People who used the service or their relatives did not raise any issues about staffing levels in the home. One person in their questionnaire said “the carers are excellent”. Southview Close DS0000010226.V364576.R01.S.doc Version 5.2 Page 20 We saw good interactions between people who use the service and staff. Staff spoken with, demonstrated a good knowledge and understanding of individuals needs. We saw people who use the service to be comfortable and relaxed with staff. Minutes of staff meetings were seen. These take place regularly and enable information to shared among staff members. The organisation has an appropriate recruitment policy. We looked at five staff files and found that they all contained an application form, a recent photographs, two references, CRB check and proof of identity. One staff confirmed that their induction was very good and covered what they needed to know. The home currently has two staff vacancies which they are in the process of recruiting for. The voids are currently being filled by current staff working additional shifts or agency staff who are fully aware of the residents needs. Three staff confirmed that they received regular supervision and that they felt supported. Appraisals take place annually and were currently in hand. All staff spoke positively of the training in place maintaining that it enhanced their practice and enabled them to provide a high standard of care to the residents. The staff survey received said “I think the service is doing their best to make the people we support comfortable and happy in themselves through ensuring their staff are given appropriate training”. The majority of staff have complete their NVQ , one staff member spoke of the support she had received from her colleagues in pursuing her NVQ 2 which she had just received. All staff receive relevant training that is focussed on delivering improved outcomes for residents. The home puts a high importance on training and staff report that they are supported through training to meet the individual needs of people in a person centred way. A system is in place for ensuring that staff keep up to date with mandatory training. Southview Close DS0000010226.V364576.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 this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service is well managed. The management style is proactive and open. People are supported to contribute their ideas to the running of the home. The health and safety of the people living in the home and staff working there is maintained. EVIDENCE: Discussion with the Registered Manager indicated that she has a clear understanding of the strengths and needs of the residents and staff in the home. There is a commitment to running the home in people’s best interest and to seeking their views about how the home is run. There is a strong focus on person centred thinking, of staff with residents being involved in shaping Southview Close DS0000010226.V364576.R01.S.doc Version 5.2 Page 22 service delivery. The manager leads and supports a strong staff team who are trained too a high standard. Monthly meetings take place which seeks the views of the people living in the home. They are also encouraged to raise any concerns that they have. The AQAA contains clear, relevant information that is supported by a wide range of evidence. The AQAA lets us know about changes they have made and where they still need to make improvements. We saw staff meeting records. At these meetings, staff are given the opportunity to discuss practice issues, and are updated on changes to people who use the service and changes within the organisation. The area manager visits monthly and will speak to residents and staff, examines records and sends a copy of his report to the Commission. A quality Assurance system is in place which seeks the views of residents, relatives and stakeholders. The organisation has introduced “The Big Respect” which is an annual planned visit by a senior manager who spends most of the day in the home talking to residents, staff and visitors seeking their views of the service as well as observing practice. A number of health and safety records were seen which were well maintained and up to date. These included fire equipment, fire safety, water temperatures and fridge and freezer. A copy of the Landlords gas record was also seen. No health or safety issues were identified during the visit. Southview Close DS0000010226.V364576.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 3 2 3 3 3 4 3 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 4 25 3 26 4 27 3 28 4 29 3 30 4 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 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 3 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 x x 3 3 Southview Close DS0000010226.V364576.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. 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. Refer to Standard Good Practice Recommendations Southview Close DS0000010226.V364576.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 Southview Close DS0000010226.V364576.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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