Care Home: Springpark

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What the care home does well The staff have an excellent understanding of people`s needs and make good use of health care professionals and other specialists support. There is a strong commitment by the Manager and staff to person centred planning and ensuring that people`s rights are promoted and respected. People are supported to make their own decisions about their lives. `Active Support` is being used to help people develop their independence skills and be active and involved during the day. The new Manager reviews the service continually and has identified areas that will make the service better for people, such as looking at new ways of communicating with people. People that live in the home have busy lives and are supported to do the activities they want, including going to college and getting a job. People have their health needs fully met and they are encouraged to manage their own health appointments. The home ensures people are safe. What has improved since the last inspection? The new Manager has made lots of improvements to the service since she came to the home. The company has introduced person centred planning and Active Support and the Manager and Deputy Manager have promoted this within the home. All the risk assessments have been updated to make sure people are safe in the home. Health action plans have been introduced to help people plan for their own health needs. There are more opportunities for people to do activities in their local community and to go to college and work. Two written references are now taken up before new staff start in the home and staff have completed more training. The Manager has booked to attend a conference on ageing so that she can ensure people`s needs are met as they get older. Improvements have been made to the home including redecoration of some areas and new carpets being ordered. People are asked their views of the service now as part of the quality checks made on the home. What the care home could do better: It is recommended that Person centred planning be used to help people communicate their hopes and dreams for future. This is also recommended to help people express their wishes about personal relationships and sexuality. There have been no requirements made in this report. CARE HOME ADULTS 18-65 Springpark Springpark Camden Road Lingfield Surrey RH7 6AF Lead Inspector Jo Griffiths Unannounced Inspection 12th March 2008 10:00 Springpark DS0000013793.V359454.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 Springpark DS0000013793.V359454.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. Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springpark Address Springpark Camden Road Lingfield Surrey RH7 6AF 01342 832583 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) Ashcroft Care Services Ltd Vacant Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (3) of places Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 2006 Brief Description of the Service: Spring park is a small residential home that provides accommodation and support for three adults with moderate to severe learning disabilities. The service is owned and managed by Ashcroft Care Services who have a number of similar homes in the southeast. The home is in a quiet residential area near, within close proximity of shops and other community amenities near the town of Lingfield. The home is on two floors; the communal facilities of dining area, lounge, kitchen, and utility area, together with two service users bedrooms are all on the ground floor. A third single bedroom with en-suite shower and an office are situated on the first floor. There is an attractive and well-maintained garden to the rear of the home for service users to enjoy. Parking is available at the front of the house and outside on the road. The weekly fees for this service range from £1300 - £1800 depending on individuals assessed needs. Springpark DS0000013793.V359454.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 3 Star. This means the people who use this service experience excellent quality outcomes. This key inspection took place on 12th March 2008 between 10.00am and 3.00pm. There are three people that live in the home and they were all involved in a music session at home when the inspector arrived. Since the last inspection a new Manager, Holly Robins, has been appointed and is in post. Holly has applied for registration with CSCI. The people living in the home were not able to verbally communicate their views of the service, but observations of the support they receive were made as part of this inspection. The Manager gave feedback on the progress made since the last inspection and some of the documents and records were inspected. There is an easy read version of this summary available with the final report. What the service does well: What has improved since the last inspection? The new Manager has made lots of improvements to the service since she came to the home. The company has introduced person centred planning and Active Support and the Manager and Deputy Manager have promoted this within the home. All the risk assessments have been updated to make sure people are safe in the home. Health action plans have been introduced to help Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 6 people plan for their own health needs. There are more opportunities for people to do activities in their local community and to go to college and work. Two written references are now taken up before new staff start in the home and staff have completed more training. The Manager has booked to attend a conference on ageing so that she can ensure people’s needs are met as they get older. Improvements have been made to the home including redecoration of some areas and new carpets being ordered. People are asked their views of the service now as part of the quality checks made on the home. 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. Springpark DS0000013793.V359454.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 Springpark DS0000013793.V359454.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): Standard 2 People that use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. That people moving to the home can be assured they will have an assessment of their needs and will be offered a place at the home only if their needs can be met by the service. EVIDENCE: The three people in the home have lived together at Springpark for many years. There have been no new admissions to the care home since the last inspection of this service. The assessment documentation for two of the people in the home was inspected. It was found that these contained sufficient information about people’s needs in all areas that they may require support. When inspecting the individual plans for these two people it was clear that the assessment of their needs had formed the plan. The assessments had been reviewed recently to ensure there were no changes. Springpark DS0000013793.V359454.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): Standards 6, 7 and 9 People that use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have a person centred plan that ensures their needs are met in the way they prefer. People are supported, through person centred planning, to make decisions about their lives. People are supported to take reasonable risks as part of an independent lifestyle. EVIDENCE: During the inspection there were opportunities to observe the people that live in the home in their daily activities and routines. It was clear that the staff have a good understanding of people’s individual needs and were following individual’s plans. The people living in the home appeared relaxed and happy. Staff spoke to them in a respectful manner and supported them to make choices. This Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 10 included making decisions about where to go for lunch and for activities for that afternoon. Each person has an individual plan that outlines their assessed needs and how these will be met by the service. The plans for two people were inspected in detail. The plans contain guidelines for staff on how to support the person with their daily routine. The guidelines have been recently reviewed and signed by staff to confirm they have read them. The plans reflect the needs that were identified in the assessment. Both people also had a care plan from their funding authority. The individual plans reflected the needs that were included in the funding authority care plans. Each care plan had been reviewed and the Manager said they are reviewed with the care Manager every six months. The last review for both people showed that the service continues to meet their needs. Risk assessments have been completed for daily activities and also for any individual risks, for example, aggressive or self-injurious behaviour. The risk assessments were reviewed in February 2008. Ashcroft Care has a team of behavioural specialists who provide support to the home. They have supported the Manager to update guidelines for preventing and managing self-injurious behaviours. Active Support has been introduced to ensure that people are appropriately supported during the day and are supported to be as independent as possible. The Manager said this has helped reduce difficult and challenging behaviours that were previously presented by some people in the home. Individual’s records showed that the frequency of challenging behaviour had significantly reduced. This is extremely positive for the people in the home as it has allowed them to increase their opportunities for social networking. Records of Active Support are maintained and show that people are being supported to be involved in the running of the home and to do as much for themselves as possible. The Manager gave examples of how people with physical disabilities, complex needs and non-verbal communication are supported to be involved in daily tasks. The Active Support plans are monitored regularly by the Manager and the behavioural specialist team. Also within the care plan were identified goals that people have been working to achieve. The goals are mainly focused on developing daily living skills. Some of these have now been achieved and should be incorporated into the person’s daily routine. The Manager stated that she plans to work with each person to help them set new goals. It is recommended that this be done through person centred planning to ensure they are based on the person’s aspirations. Since the new Manager has been in post she has introduced person centred planning as a way of working with individuals to plan the support they wish to receive. The person centred plans have been completed with photos, symbols and pictures to help each person be involved in their plan. The plans include the things that are important to each person and the way they would like to be Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 11 supported. They also include a health action plan. The Manager said that she is continuing to work with people on their plans with regard to the way they communicate. For example, it has been found that working with photos and symbols works well with two people in the home, but that other ways of communicating need to be found for the other person. It is planned that objects of reference will be introduced. The person centred plans are an excellent start and show a commitment by the team to supporting people to make their own life choices. It is recommended that the plans be further expanded to include aspirations and goals for the future. The Manager has a good understanding of the Mental Capacity Act and people’s rights to make their own decisions. Springpark DS0000013793.V359454.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): Standards 11, 12, 13, 14, 15, 16 and 17 People that use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. People in the home are supported to make their own decisions about the activities they wish to do. They lead busy and interesting lifestyles that suit their tastes and needs. People are supported to play a valued role in their local community and to build and maintain relationships. People’s rights as individual citizens are promoted and respected. People in the home enjoy a healthy diet and are supported to plan their own meals. EVIDENCE: Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 13 Prior to this inspection visit two unannounced attempts had been made to visit the care home, but people were out and about doing their daily activities. This is a good indication that people lead busy lifestyles. Each person has a weekly activity planner that they have been involved in devising. The activities they do are individual to them and are based on things they say they enjoy and also new things they would like to try. Each person has something planned every day. The activities are a mixture of educational activities, daily routine activities and leisure. Examples include, shopping, going to the café, eating out, going to the pub, swimming, church, line dancing, rambling club, music group, art, walks, preparing meals, and leisure day trips. The records in the individual plans show that people are supported to do these activities consistently, but their choice not to do an activity or to do something different is respected. During the inspection people were enjoying a music session with an external musician that visits the home. Later people went out for lunch, coffee and bowling. One person uses a picture timetable to help them plan their activities for the day. This was implemented with the help of the community learning disability team. The Manager said this has reduced a lot of anxiety for the person as they are able to see what they have planned. Records showed that one person is being supported to apply for college courses that are of interest to them. The Manager said that further development of the person centred plans would include planning any educational or skills development opportunities with people. The same person has expressed a wish to get a part time job. The Manager is arranging for some volunteer work at a local shop to help the person develop the skills they need for employment and see if they enjoy the role. The people that live in the home have profound learning disabilities and some complex needs. The Manager spoke passionately about ensuring that they have equal opportunities for activities, work and leisure as everyone else in society. Records show an increase in opportunities for people since the new Manager has been in post. As described in the previous section of this report, Active Support is being used to support people to be active and involved throughout the day and not just when they have structured activities. This has been fully implemented since the last inspection. When at home people are supported to be involved in meal preparation and household tasks. Records show people also enjoy foot massages, listening to music and watching TV. One person has pet guinea pigs in the garden and is supported to look after them. The garden has patio area for use in summer. There are puzzles and books in the home for people to use. Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 14 The person centred plans showed that people were being supported to choose and plan their holiday for this year. The Manager said that opportunities for accessing the community and getting to know local people has been a priority recently. People have enjoyed attending church and using local shops and restaurants. The Manager said that through increasing community involvement people will have more opportunities to meet new people and build relationships. Some staff and the Manager have had training in sexuality and relationships. Person centred plans could be further developed to take account peoples needs regarding relationships and intimacy. The Residents rights charter is included in the individual plan. This tells people what their rights as citizens and tenants of the home are. Each person is supported to manage their money when they go out and there are safeguarding systems in place for their finances in the home. Service users views have been incorporated clearly in the person centred plans and individual plans. The menu is planned with the people in the home weekly and they help with the food shopping. Records are kept of the meals provided and the menu choices each person makes. One person has a dietician involved in their individual plan. It was evident that the staff were supporting the person to follow the advice of the dietician. Staff supported people to make their own drinks when they wished during the inspection. The Manager is planning to arrange nutrition training for staff. Records show that mealtimes are flexible and supper and evening drinks are offered. Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 15 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): Standards 18, 19 and 20 People that use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported with their personal care needs in the manner they prefer. They are supported to manage their own health needs to ensure they are met and are supported to manage their medication safely. EVIDENCE: People’s needs with regard to personal care are included in the individual plan. This gives staff the information they need about how the person prefers to be supported. The plans take into account the person’s preference for bath or shower and their preferred time of getting up. Equipment is provided in the bathroom to help those with mobility difficulties. Each person has a health action plan and they are encouraged and supported to manage their own health needs. The health action plan outlines the support the person may need for health check-ups and health screening. The Manager said that staff work with people to help them understand healthy eating and maintaining a healthy lifestyle. Individuals’ records show involvement by a number of healthcare professionals including, GP, optician, chiropodist, dentist, Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 16 community nurse, physiotherapy, dietician, occupational therapist, psychologist and behavioural specialist team. The Manager said that recent referrals had been made for support from a physiotherapist and a continence advisor. The Manager had booked a meeting with the psychiatrist to review individuals’ medication. Everyone living in the home requires staff to administer their medication, but is encouraged to be as independent as possible. All the staff that administer medication have undertaken training in this area and the certificates were held on their files. In addition to a one-day course they also complete a three-unit workbook provided by Lloyds pharmacy. All staff have an assessment of their competence to give medicines. The Manager described how one person was recently supported to consult with their GP about changing the time of a medication dose to better fit their choice of lifestyle. Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 17 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): Standards 22 and 23 People that use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People can be confident that their concerns will be taken seriously. People are safeguarded from harm and abuse by the practices and procedures in the home. EVIDENCE: The complaints procedure is included in the Service User Guide and is displayed on the wall. The Manager works on shift most days per week and ensures she spends 1-1 time with each person weekly to see if they are happy with their care and if they have any concerns. Each person also has a keyworker in the home and a care Manager from their funding authority they can talk to if they have any concerns. The Manager said she would like to do some further work to help people understand the complaints procedure in a way that best suits their communication needs. There have been no complaints received by the home or by CSCI. There have been no Safeguarding adults referrals made since the last inspection. There is a policy in place for safeguarding adults that reflects the Surrey multi agency policy for reporting allegations of abuse. The Manager has good understanding of the Surrey multi agency safeguarding procedures. All staff undergo a Criminal Records check before they are employed and complete a training course in Safeguarding adults. Springpark DS0000013793.V359454.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): Standards 24, 25, 27, 28, 29 and 30 People that use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides people with a comfortable, clean and safe living environment. People’s bedrooms meet their needs and they have access to appropriate bathroom facilities and shared space. Adaptations have been made where necessary for those with mobility difficulties. EVIDENCE: The home provides a comfortable and homely environment for the people that live there. Each person has their own large bedroom and has been supported to choose the décor and personalise them with their belongings. One person is currently using a bed rail to prevent them from falling at night. The Manager has made a referral to the Occupational Therapist for advice on more appropriate measures that could be taken. Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 19 There are a sufficient number of bathroom facilities to meet individuals’ needs. Adaptations have been made and equipment provided to assist people with mobility difficulties. There is a large kitchen that is accessible to the people that live in the home. They are supported to help prepare their own meals. The laundry room is situated off the kitchen and, following a recent Environmental Health visit; new risk assessments for reducing infection control risks have been implemented. The Manager has also implemented the Safer Food Handling book recommended by the Environmental Health department. The home is clean and hygienic and well maintained. New carpets had been delivered for two of the bedrooms and the lounge. The Manager was waiting for these to be fitted. The lounge suite has become worn and it is planned in this years budget that this will be replaced. An armchair in one person’s room also needs replacing as the seat is torn. The Manager said that this had also been accounted for in the budget. There is a large rear garden with patio and table and chairs for use in the summer. Springpark DS0000013793.V359454.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): Standards 31, 32, 33, 34 and 35 People that use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People in the home are supported by sufficient numbers of qualified and competent staff to meet their needs. They can be assured that staff have clear job roles and accountable responsibilities. They are safeguarded by the home’s procedures for recruiting new staff. EVIDENCE: There are always at least two staff on duty during the day and there is one waking night staff. Two people in the home have allocated 1-1 hours and these were being used appropriately on the staff rota. There are enough staff on duty to support people with their planned daily activities. The recruitment files for two new members of staff were inspected. These showed that the appropriate checks had been made before they were employed to safeguard people in the home, including a criminal records check and two references. All new staff undergo an interview with the Manager of the home and are required to work alongside experienced staff as part of their induction. Both members of staff had begun work on their ‘skills for care’ Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 21 induction. All staff are issued with a job description and the General Social Care Council (GSCC) code of conduct. The training files for the two staff were also inspected. These showed that courses have been completed for one member of staff in Sexuality, Risk assessment, Safeguarding adults, Moving and Handling, Equality and Diversity, Epilepsy, Medication, Fire, Makaton and Infection control. The newest member of staff has not yet completed the required training but continues to work on their induction. Evidence was seen in the file that courses have been booked within the next two months for Food Hygiene, Safeguarding adults, Autism, Health and Safety and Moving and handling. Of the seven members of staff employed at the home four have an NVQ level 2 or above. One member of staff is planning to start the NVQ after their probation period. The Deputy manager has Registered Managers Award. Springpark DS0000013793.V359454.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): Standards 37, 39 and 42 People that use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People in the home benefit from an experienced and competent Manager who ensures the home is run in their best interests. The health and welfare of the people that use the service is promoted and protected. EVIDENCE: Since the last inspection a new Manager has been appointed and is applying for registration with the Commission. She has previous experience of managing similar services and has completed the NVQ level 4 in management. She is due to start the Registered Manager’s Award. The Manager has completed a number of training courses including Person centred planning, Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 23 Sexuality, Challenging behaviour, Medication, Food hygiene and Safeguarding adults. She has also booked to attend conference on the needs associated with ageing. Since being in post the new Manager has made a number of improvements to the service including introducing Person centred planning, updating training records, improving the décor of home, liaising with health care professionals to review people’s medication and improving the opportunities for activities for people. The organisation has a Quality Assurance Manager who carries out an annual audit of the service. There are also monthly visits by the provider to assess the quality of the care in the home. Quality assurance surveys were sent to service users, family members and Care Managers in December 2007. The Quality Assurance Manager is going to collate the results and produce a report. The manager of home is looking at different ways to help people communicate their views, by use of photos and objects of reference. The Manager informed the Commission, through the AQAA, that all equipment in the home has been serviced and safety checked. Since the last inspection a new fire risk assessment has been completed as well as a risk assessment for the risk of scalding from radiators. The organisation is reviewing the fire doors in the home to ensure they meet fire regulations. Springpark DS0000013793.V359454.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 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 3 12 4 13 4 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X X 3 X Springpark DS0000013793.V359454.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. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA7 YA15 Good Practice Recommendations It is recommended that person centred plans be expanded to include peoples hopes and aspirations for the future. It is recommended that person centred plans be expanded to include peoples needs and wishes with regard to their sexuality and personal relationships. Springpark DS0000013793.V359454.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Springpark DS0000013793.V359454.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. 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