Care Home: Tova

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What the care home does well The home makes sure that it can look after everybody properly and helps people to do as much as they can for themselves. The residents are assisted to lead an interesting and active life and they are helped to enjoy themselves as much as they can. The staff make sure that everything is kept clean and have developed areas such as the garden and sensory room, so that it is a good place for residents to live. The staff are very good, they make sure that residents `come first` and are always as safe as they can be. Staff are helped by the manager and other senior staff to be good at their job and go on training courses when they need to, to make sure that they always look after people in the best way possible. What has improved since the last inspection? The home carries on trying new ways of talking to people and trying to understand what their opinions are. What the care home could do better: The home could continue to find ways of looking at the care that they give to make sure that it stays as good as it is now. CARE HOME ADULTS 18-65 Ezra Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ Lead Inspector Kerry Kingston Unannounced Inspection 28th November 2007 10.30 DS0000033977.V349860.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 DS0000033977.V349860.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. DS0000033977.V349860.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ezra Address Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ 01344 755549 01344 7731714 ezra@norwood.org.uk bucketsandspades@norwood.org.uk Norwood Ravenswood Ltd T/A Norwood 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) Mr Martin Rowe Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000033977.V349860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th September 2006 Brief Description of the Service: Ezra cares for eight adults with learning and associated physical disabilities. It is set in Ravenswood Village, which is a Jewish community. Ezra’s underpinning ethos is derived from the Jewish faith and the beliefs practices and values of Judaism underpin all aspects of residents lives. The home is a bungalow and there are a variety of aids and adaptations around the building to allow residents to move about more independently. All of the bedrooms are single and none of them have en-suite facilities. There are two communal toilets and two communal bathrooms. The fees per week for the home are between £65,000 and £110,000 per annum. Additional charges are made for chiropody, aromatherapy and magazines and papers. DS0000033977.V349860.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report for the key inspection of the service, which included a routine unannounced site visit. This took place between the hours of 10.30 am and 3.30pm on the 28th November 2007. The information was collected from the Annual Quality Assurance Assessment, a document sent to the service by the Commission for Social care Inspection and completed by the manager of the service, surveys which were sent to people who use the service, other professionals and families of residents. Four surveys from families, two from other professionals and two from staff were returned to the Commission. There are, currently, seven people resident in the home. Discussions with staff members and the Manager took place. Most people who use the service have no or limited verbal skills and use their own unique methods of communication, therefore observation was also used as a source of information throughout the visit. A tour of the home and reviewing residents’ and other records were also used to collect information on the day of the visit. The home offers excellent standards of care to people with complex and diverse needs. What the service does well: The home makes sure that it can look after everybody properly and helps people to do as much as they can for themselves. The residents are assisted to lead an interesting and active life and they are helped to enjoy themselves as much as they can. The staff make sure that everything is kept clean and have developed areas such as the garden and sensory room, so that it is a good place for residents to live. The staff are very good, they make sure that residents ‘come first’ and are always as safe as they can be. Staff are helped by the manager and other senior staff to be good at their job and go on training courses when they need to, to make sure that they always look after people in the best way possible. DS0000033977.V349860.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. DS0000033977.V349860.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 DS0000033977.V349860.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use the service experience good quality outcomes in this area. The homes properly assesses the needs of prospective residents and ensure that all the necessary equipment and staff skills are available to enable them to meet individuals’ needs, however special and diverse. A detailed care plan is developed from the assessment and this is reviewed regularly to make sure that the individuals needs continue to be met in the new home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been one new admission since the last inspection. She was admitted in August 2007 and has a full and detailed residential care assessment. Her support plan is still being developed (a ‘work in progress’). It is altered as the home get to know her better and is regularly reviewed. A transitional plan for her move from a children’s unit was in place and there was a transitional review on 19th August 2007. Her care plan is reviewed monthly and amended, as required, amendments are made frequently as staff get to know her better and are able to more accurately interpret her communication systems. DS0000033977.V349860.R01.S.doc Version 5.2 Page 9 The home is clear about what special equipment people may need, to meet their diverse physical needs and ensure it is in place prior to admission. More specialised equipment is sought, as necessary and those needs are identified. DS0000033977.V349860.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 and 9. People who use the service experience excellent quality outcomes in this area. People have detailed and comprehensive care plans and are helped to make as many decisions about their lives as is possible. Activities are properly risk assessed to ensure peoples’ independence is maintained, as far as is possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five care plans were seen, they are of good quality being detailed and including equality and diversity issues. The support plans, which form part of the care plan, include people’s assessed and changing needs, how people are enabled to make decisions and how they communicate those decisions. DS0000033977.V349860.R01.S.doc Version 5.2 Page 11 Support plans also note morning routines, personal care, what I like and don’t like and how I like things to be done, teeth cleaning, nail care, personality, behaviour, relationships, sexuality, domestic skills, mobility, eating and drinking, mealtimes, medical and healthcare, laundry, financial assistance /status, normal routine, sleep patterns, night support, safety at night and bathing routine. A monthly report is written on all residents, which include the headings, health and well-being, activities and outings, appointments past and future, communication and family contact. These are reviewed fully a minimum of annually, by a multi disciplinary team, the resident and their families, as appropriate. It is evident that if the care plans need to be amended they are changed quickly in response to changing needs and the changes are well recorded. Recordings in peoples’ daily diaries noted what decisions and choices people had made during the day and how people had made their wishes and views known to the staff. There were examples recorded of how staff had offered people choices and how successful the chosen strategy had been. Staff were observed offering people choices and decision-making opportunities, throughout the duration of the visit. These opportunities are limited by peoples’ ability and communication levels, but staff were seen to understand some subtle communication methods and offered as much support for people to make their own choices, as possible. Risk assessments are in place, as appropriate to the needs of the individuals for all aspects of their care. These are supported by clear and detailed guidelines to ensure that people are protected but able to be as independent, as possible. Risk assessments and guidelines are reviewed regularly, the date of the next review is always noted and are signed by all staff members. DS0000033977.V349860.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. People who use the service experience excellent quality outcomes in this area. The home provides people with opportunities to participate in a variety of activities to ensure they can achieve a positive lifestyle, whatever their diversity and equality needs. Residents are helped to make as many decisions for themselves, as they are able and are supported to maintain their relationships, outside of the home. People get good quality and varied food and are assisted with their meals patiently and respectfully, as necessary. This judgement has been made using available evidence including a visit to this service. DS0000033977.V349860.R01.S.doc Version 5.2 Page 13 EVIDENCE: Each person has an activity plan for the week, these are developed from their individual aims and objectives, noted at reviews. People also choose, generally by the way they behave whilst participating in activities, what they like to do. Staff interpret people’s behaviours to gauge the individuals’ enjoyment of activities. Activity programmes are displayed on a board in the office and residents’ participation is noted in their daily diaries. A mixture of ‘in house’, village and community activities are provided for the residents. The home has been developing an activities programme so that people can participate in more ‘in house’ activities, if they choose, but this is still in the early development stage. One person has been supported to visit family abroad (1:1 staffing was provided and appropriate risk assessments such as epilepsy on an aircraft were all in place) . One person is supported to go to church every Sunday, as she is the only person in the home who is not of the Jewish faith. The home is very aware of cultural needs and issues the non-Jewish person is helped to celebrate Christmas in a way that is inclusive but not offensive to others. Records showed that people go to town to buy clothing and other personal items, they have been to the cinema and theatre, recently. The manager described how one person used to go ski-ing although her health no longer allows this activity. A survey from a family member said ‘they make sure the week is interesting and active’. Staff were observed participating in 1:1 activity with two people, one person was at school and others were ‘in and out’ during the day. The home has a sensory room that is well used and a sensory garden with a ‘heated summer house’ so people are able to have a change of environment all year round. DS0000033977.V349860.R01.S.doc Version 5.2 Page 14 The garden and ‘summer house’ have been created and developed by the staff team, residents and families and funds have also been raised to continue the ongoing project. The garden includes a meandering pathway, arbours to sit in, sculptures and other areas of interest, the manager confirmed that it is very much enjoyed by the residents, especially in good weather. People are kept in contact with their families and a section of the daily diaries note any contacts with families or any actions, by staff, to facilitate visits to families and friends. One person visited family who live abroad for a week, another is taken to her mothers if her mum is not able to get any transport to visit. All residents have some family contact, families are invited to reviews and any events, as appropriate. The four family surveys returned to the Commission noted that the home usually or always keeps in touch with them about the care of their family members. Menus seen were varied and nutritious, staff have good knowledge of the special needs of the residents with regard to their diverse nutritional and cultural food needs. The nutritional and cultural/religious food needs of the residents are included, in detail, as part of the induction programme. Three people have a ‘normal’ diet, one has liquidised food, two have soft food and one person is fed through a stomach tube (P.E.G). Staff are trained in supporting someone with artificial feeding and they are clear when they need to seek the support of specialists external to the home. Weight charts are kept for those who have any nutritional issues, including those who are encouraged to follow a healthy eating regime. People are encouraged to choose the food they like, this is generally gauged by staff offering as many options as is practicable, including new and different foods and observing their reactions to it. Staff were observed helping people with their meal sensitively and respectfully. The residents have their meals in two sittings so that staff can spend plenty of time with those people who need it. DS0000033977.V349860.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): 18,19,20 and 21. People who use this service experience excellent quality outcomes in this area. People’s physical and emotional needs are very well met, in the way that they prefer. Their cultural and diversity needs are an integral part of their individual support plans. People receive appropriate health care and staff are alert to any changes in peoples’ health and well being, seeking support from healthcare specialists as necessary. Medication is administered as safely as possible. This judgement has been made using available evidence including a visit to this service. DS0000033977.V349860.R01.S.doc Version 5.2 Page 16 EVIDENCE: Five care plans were seen, they incorporate a support plan which includes personal care with a detailed record of what people like and don’t like and how they like to be treated physically and emotionally and how they like to be communicated with. Staff are aware of gender issues, it is an all female resident group. There is only one male staff member, the manager, who does not participate in personal care. The staff were able to discus the positives and negatives of a single sex home and detail how they overcome the negatives such as contact with males during daily activities. The support plan also includes mobility, eating and drinking, mealtimes and peoples’ diverse physical and sensory needs (one lady has no sight.) Her communication needs are clearly recorded, as are her reactions and ways of communicating back. Medical and healthcare are included on the support plans and detailed records are kept in individuals’ files and recorded on the monthly care plan review (summary). Health and well-being is a heading on the summary, it also includes past and future appointments and the results of any appointments or contacts with other health professionals during the month. The daily notes with regard to health, the healthcare records and healthcare plans cross-reference with the support plans to ensure all care is being given as required. Reviews are completed monthly by key workers and at least annually by a multi-disciplinary team of people including the resident and their family members, if appropriate. It was evident that if things need changing they are changed in a timely way and this is recorded. Permission for medical interventions is taken by using a ‘consent pathway’, which is a multi disciplinary meeting to ensure that any decisions taken are in ‘the best interests’ of the individual. Comments received by family members included ‘wonderfully looked after by a devoted staff team’, ‘Staff were with them the whole time that they were in hospital’, ‘They respect her personality’, ‘they are very respectful’, two other professionals said ‘ they provide a high level of care’, ‘they treat as individuals, respect privacy and give good physical care’, one commented that they could be better at ‘ensuring that the person accompanying the patient is aware of exactly what their problem is and have a history of the illness’. One person has been in hospital several times over the past few months, it is clear from her records that staff are aware of the reasons for her frequent admissions and DS0000033977.V349860.R01.S.doc Version 5.2 Page 17 are changing her support plan as often as necessary, to ensure that the care they offer meets her current needs. The home works hard to ensure people have equal access to healthcare and staff meet the diverse personal and emotional needs of the individual as well as the acute medical ones. One person has died since the last inspection, all residents attended the funeral and a memorial is planned, the home has a cultural advisor who assists with these events and the residents’ files have the individuals or families wishes recorded. Staff were observed communicating with people in a very respectful and sensitive manner, their dignity was preserved at the mealtime and residents were communicating with staff who were responding to their limited and subtle communication methods, quickly. Staff are trained to administer medication before they are allowed to do so. The home uses the NOMAD system, which is a system that is dispensed by the pharmacist and administered by the staff. Medication is kept in a locked medicine cabinet in the office and can only be administered by two staff. There was a discussion about the most effective method of stock control for liquid medications and the manager agreed to review the current system. Medication records and files are comprehensive and detailed and include guidelines of when to give medication prescribed by the doctor ‘ to be given when necessary’, they also note how people communicate that they are in pain or physically distressed. The small sample of medication administration files seen were accurate and the manager advised that there are only occasional medication errors, immediate action is taken and if the procedure has not been adhered to by staff, disciplinary action is taken. DS0000033977.V349860.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. Complaints are properly managed, the home works hard to interpret peoples’ views and opinions and acts upon them, if possible. People are protected from all forms of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure that is presented in a user friendly format, the residents in the home would be unlikely to use it without assistance but the staff are alert to any behaviour or health changes that could indicate that people are not happy. All family surveys, returned, noted that they knew how to complain and who to complain to. The manager confirmed that the home has not received any complaints since the last inspection, minor concerns are dealt with immediately and do not become complaints. There was discussion about what constitutes a complaint and what concerns should be recorded, the manager advised that this has been under discussion with the staff team. The staff member spoken with confirmed that she had received safeguarding adults training and was very clear about how she would react to any concern about abuse in the home. DS0000033977.V349860.R01.S.doc Version 5.2 Page 19 She had a good understanding of her protective role and legal obligations to the residents. The training records showed that all staff had received ‘safeguarding’ training (P.O.V.A). The Commission for Social Care Inspection has received no information with regard to complaints or safeguarding adults concerns about the service. Residents’ finances were not looked at but people are participating in outings, activities and holidays and are well dressed, there appeared to be no financial constraints for individuals and the financial policies and procedures are robust. DS0000033977.V349860.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People experience good quality outcomes in this area. The home is well kept and maintained. The comfort, safety and interests of the residents have a direct influence on the environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is clean and well maintained, there is a lounge and sensory room area that the manager advised is well used by individuals. The dining room is also used as an activity room and it was seen being used for both purposes, on the day of the visit. Bathrooms and toilets are very clean and individual bedrooms are personalised to peoples’ tastes and personalities. Bedrooms also include any necessary adaptations, such as lifting handling equipment, to meet the special physical needs of the residents. DS0000033977.V349860.R01.S.doc Version 5.2 Page 21 The laundry was in good order and the kitchen was clean and hygienic. The sensory garden project remains ‘ongoing’ and the manager said that the residents enjoy using the ‘summer house’ that has been heated so that it can be used all year round. Residents, staff, families and friends are involved in the garden project, raising money and doing practical work. The home does not have a specific annual refurbishment plan but work is undertaken as necessary and the home is likely to be fully refurbished when the organisations’ development plans are completed (to open new homes on the site and for this home to become a more specialised unit.) DS0000033977.V349860.R01.S.doc Version 5.2 Page 22 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 and 35. People experience excellent quality outcomes in this area. The home has a well-trained and qualified staff team who are able to meet all the needs of the people who use the service. The staff team is highly motivated, the needs of the residents are paramount and an integral part of the effective working practices of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The organisation offers numerous opportunities for staff training, including professional qualifications. Training records showed that staff have all received health and safety training, which is up-dated as necessary. They also attend training courses that are about the specific needs of the residents such as PEG feeding, epilepsy and anything else they might need to ensure the diverse needs of the residents are properly met. DS0000033977.V349860.R01.S.doc Version 5.2 Page 23 Staff also have the opportunity to attend training that will assist with their personal and professional development such as management training and N.V.Q. 3 and 4 training. Over 70 of the staff team have an NVQ 2 or above qualification and all but one of the rest of the staff team are working towards it. Senior staff team members have management and assessor training. The organisation has a training department and a commitment to ensure that all staff are properly trained and qualified for their roles. Family and other professionals surveys noted, ‘ Regular training for any condition experienced by the patients such as P.E.G. feeding’, ‘The team work together are professional and supportive’, ‘The team is excellent and meet all their needs’, ‘they look after them in the most supportive way’, ‘an excellent facility’. The staff team were observed treating people with great respect and sensitivity and following the written care plans, it was evident that they had a good understanding of the day- to -day needs of the residents. The home has a minimum of four staff on duty, during daytime hours and two waking staff at night. Staff and the manager confirmed that they have time to do all the necessary tasks and are able to spend time with individuals, two staff noted that ‘more staff could help on occasion, particularly with appointments and activities’. The human resources team, in the administration offices, holds recruitment records. Two recruitment files were seen and contained all the necessary information to ensure staffs’ safety. There was a discussion about the manager ensuring that the references for overseas workers were properly validated and the validation method noted on the files. The issues around the cultural balance of workers in the home are ongoing and the manager is very aware of any language or communication difficulties that may cause difficulties. Staff are supervised regularly by the senior staff team and have an annual appraisal. One staff member stated that the home always puts the ‘clients needs first’ and another said that the seniors ‘look after the staff’. DS0000033977.V349860.R01.S.doc Version 5.2 Page 24 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 experience good quality outcomes in this area. The home is well managed, it continues to develop to improve the outcomes for the people who live there and ensures that it is as safe an environment as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post for approximately four and a half years and has all the necessary experience and qualifications, he is currently pursuing a foundation degree course, supported by the organisation. DS0000033977.V349860.R01.S.doc Version 5.2 Page 25 The manager has a good understanding and knowledge of resource and funding issues and the home raise money for ‘luxury’ items such as the sensory room and garden. The quality assurance system is not fully developed but there are plans to find ways of getting residents views more accurately represented. One resident attends the village residents’ forum that meets once every two weeks. The home does not have an annual development plan but there are major development plans for three homes in the village, these include Ezra. It is planned that the home will be fully refurbished and become a more specialised service for a group of people who have similar needs. The development of individual communication systems and further activities are also ‘ongoing’. A sample of Health and Safety records were seen and all were properly completed on a regular basis. Accident and incident forms are kept, these include a detailed record of any necessary action to minimise recurrence, where possible. Accident and incident reports are audited monthly by a staff member and the service manager, who sees them during their monthly regulation 26 visits. A copy of all reports are sent to the Health and Safety advisor at ‘head office’. DS0000033977.V349860.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 4 X 2 X X 3 X DS0000033977.V349860.R01.S.doc Version 5.2 Page 27 NONE 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 DS0000033977.V349860.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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. 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