Inspection on 10/06/08 for 1-4 Windsor Drive

This inspection was carried out on 10th June 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 1-4 Windsor Drive 1 - 4 Windsor Drive Exeter Road Dawlish Devon EX7 0SA Lead Inspector Judy Hill Unannounced Inspection 10th June 2008 10:00 1-4 Windsor Drive DS0000071097.V363575.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 1-4 Windsor Drive DS0000071097.V363575.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. 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1-4 Windsor Drive Address 1 - 4 Windsor Drive Exeter Road Dawlish Devon EX7 0SA 01626 888481 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) windsordrive@dchs.org.uk Guinness Care and Support Ltd Mrs Denise C Fogden Care Home 12 Category(ies) of Learning disability (12) registration, with number of places 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 12. First inspection under current owners. Date of last inspection Brief Description of the Service: 1 – 4 Windsor Drive is registered to provide accommodation and care for a maximum of twelve people who have learning disabilities. The home is divided into two pairs of semi-detached bungalows and each bungalow provides selfcontained accommodation for a maximum of three people. The bungalows are set in grounds of a hospital on the outskirts of Dawlish and are approximately two miles from the town centre. There is a regular bus service to Dawlish and Exeter. Information about the home and the service is provided in a Statement of Purpose and a Service Users Guide, both of which are available from the home on request. As this is the first inspection to be carried out since Guinness Care and Support Limited became the owners of the business previous inspection reports are not available. The Statement of Purpose states that the fees range from £700 to £800 a week. Additional charges are made for podiatry, hairdressing, aromatherapy, private telephone installation, telephone calls, lease of transport (£71 a month), mileage (10p a mile), dry cleaning, meals and snacks out, newspapers, clothing, toiletries and other items of a personal nature. 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The information contained in this report was gained in conversation with the registered manager, staff and residents of 1 – 4 Windsor Lodge during an unannounced visit to the home that was carried out on 10th June 2008. During this visit a full inspection of the premises was carried out and records, including residents needs assessments, risk assessments, care plans and reviews and staff recruitment and training records were seen. The interaction between the residents, staff and manager was observed. Additional information was gained from documents, including the homes Statement of Purpose, Service Users Guide and an Annual Quality Assurance Assessment that had been completed before the inspection by the Registered Manager and the service history. Surveys were completed and returned to the Commission by residents, their relatives, healthcare professionals and staff. What the service does well: Needs assessments are carried out prior to admission and continued during a trial period of a month following admission. This ensures that new residents, their representatives and the service providers can make sure that the home can provide the residents with the service they need. Feedback from surveys completed for the Commission by residents and their relatives indicated that the needs of the residents are always or usually being met. An activity organiser has recently been appointed and she is responsible for arranging outings and providing in house activities for the residents and the people who live at the home are helped and encouraged to participate in social, occupational and recreational activities. Positive comments were received from some of the relatives who completed and returned questionnaires to the Commission about the care provided by the staff. The health of the residents is monitored so that timely referrals can been made to the professional health care services. 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 6 Feedback from questionnaires completed by relatives of the residents indicated that they have confidence in the manager to resolve and complaints or concerns that they may have. The premises are suitable for people who use wheelchairs. By design the home is divided into four self-contained units and this provides a homely and domestic living environment for the residents. Safe recruitment practices are used to employ new staff. This means that unsuitable staff will not be employed to work with the residents. Most of the care staff have National Vocational Qualifications in Care. The registered manager is very experienced and feedback from surveys indicates that she is held in high regard by the residents and their families. What has improved since the last inspection? What they could do better: The statement of terms and conditions contained in the Service Users’ Guide must include the amount and method of payment of fees and every resident must be given a Service Users’ Guide. The information included in the Statement of Purpose about the range of fees and extra charges should be amended to provide accurate information for prospective residents and their representatives. The residents and their families or independent advocates need to be actively involved in their care planning and reviews. The residents could be given more active support to be involved in the day to day running of their home and be given the opportunity to take annual holidays. The bathrooms would benefit from refurbishment and the broken overhead hoists in two of the bathrooms should be replaced or repaired. Feedback from surveys suggests that the staffing levels are not always high enough to meet the needs of the residents. Although the provision of health and safety related training is good, very little evidence was seen of staff training that relates specifically to meeting the needs of people with learning disabilities. This means that the staff may not be familiar with current good practice in this specialist field. 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 7 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. 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about the service provided is available from the home to people considering using the service, current residents and their representatives in a Statement of Purpose. The Statement of Purpose states that the fees can be between £700 and £800 per week however the contracts between the service provider and the commissioning authorities for two of the residents were seen and both exceeded £800. The information on the range of fees is therefore misleading and needs to be amended. A copy of the Service Users Guide was given to the Commission on request but copies have not been given to the residents. This means that the residents and their representatives may not have access to all of the information they need about the service provided. Photographs have been used throughout the Service Users Guide to make the information easier for the residents to understand. A Statement of Terms and Conditions of Residency is provided 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 10 with the Service Users Guide but details of fees charged are not included in this document. Details of the admissions procedure are included in the Statement of Purpose. These include an initial assessment by the registered manager and/or Social Services/Care Trust Care Managers, pre-admission visits to the prospective resident by the registered manager and by the prospective resident to the home. The first four weeks of admission are provided on a trial basis to enable the registered manager and staff to continue the assessment process to ensure that the service is right for the new resident and for the new resident and their representatives to ensure that the service is right for them. Records of case management and in-house assessments for two of the residents were seen during the site visit. 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. The care planning is detailed and well presented but tends to be service lead with little evidence to show that the residents and their families are actively involved in the care planning processes or that personal goals are being set. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The plans of care of two of the residents were inspected during the site visit. The care plans and risk assessments were seen to be very clearly and well presented and to contain a great deal of relevant information about how individual residents needs could be met. The care plans and reviews seen both had input from the registered manager and staff and from professional people who are involved with the residents on an individual basis, but no evidence was seen to show that the individual residents and/or their families had been actively involved in the care planning process. 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 12 Feedback from surveys completed for the Commission by residents and their families indicated that the need of the residents are always or usually being met. The Annual Quality Assurance Assessment completed by the registered manager prior to the inspection states that she is aware of the need introduce more person centred planning and that she plans to do so within the next twelve months. This should increase the ability of the residents to make decisions about their lives and to exercise choice. The home holds personal spending money for the residents. Detailed records are kept of the money spent by the residents or by the staff on their behalf and these records are regularly audited. Records were seen to demonstrate that comprehensive risk assessments are being carried out and examples seen gave clear guidance about how to minimise risk. 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. The people who live at the home are helped and encouraged to participate in social, occupational and recreational activities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some of the surveys completed prior to the inspection by relatives of the residents stated that more could be done to meet the social, recreational and occupational needs of the residents. This was also identified as an area that could be improved by the registered manager when she completed her Annual Quality Assurance Assessment (AQAA). It was noted that action had been taken to improve this provision by the time of the site visit. An activity organiser has recently been appointed and she is responsible for arranging outings and providing in house activities for the residents. In-house 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 14 activities include art and craftwork and examples of the residents work were seen during the site visit. No evidence was seen to demonstrate that the residents are actively encouraged to participate in the general day-to-day running of their home, for example housekeeping and cooking. None of the current residents are able to go out unescorted because of their physical disabilities. However, the residents lease a minibus and are given regular opportunities to go out for day trips. One of the residents said that he had been to the cinema and to a donkey sanctuary last week and would be going shopping in Exeter this week. Most of the residents have maintained close relationships with members of their families and no restrictions are placed on the rights of the residents to receive visitors at any time. Three of the eleven residents attend a day care service for two or three days a week. The residents are not given the opportunity to take annual holidays away from the home. The home has a sensory room, which is well used by some of the residents. A key worker system is in place to ensure that each of the residents has a named member of staff to take a special interest in their care. Throughout the inspection the registered manager and the care staff were observed to be interacting well with the residents and to be treating them with dignity and respect. One of the residents was seen enjoying her lunch, which had been prepared by the staff. One of the surveys completed by a relative of a resident said that the diet was “excellent”. 1-4 Windsor Drive DS0000071097.V363575.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 Quality in this outcome area is good. The provision of personal care provided is good and the health of the residents is monitored so that timely referrals can been made to the professional health care services. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Positive comments were received from some of the relatives who completed and returned questionnaires to the Commission about the care provided by the staff. One said that the personal care provided was “Excellent”, another said “The staff are excellent…they really do give personal caring and consistent support”. There were, however, some negative comments from the relatives about poor communication both between staff and between the home and themselves. Positive comments were also received about the links with health care services. A relative said “Health concerns have always been immediately dealt with” and a health care professional said, “Carers have been proactive in ensuring medical care and advice is sought whenever necessary”. 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 16 Surveys completed by the staff commented that the provision of physical care and emotional support for the residents by the staff was good. Records were seen to provide evidence of regular input from the residents GP’s, District Nurses, Speech Therapists and a private Chiropodist and Masseuse, whose services are paid for by the residents. A check was made of the storage of medicines and the administration records. Most of the resident’s medication is appropriately stored in a locked cupboard. A small amount of medication requiring refrigeration is stored in airtight containers in the domestic fridges. The need to ensure that medication is kept in locked containers was discussed with the registered manager and she agreed to purchase and use small lockable boxes. The medication administration record sheets were seen to be clearly recorded and up to date. 1-4 Windsor Drive DS0000071097.V363575.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): 22 & 23 Quality in this outcome area is good. Complaints and concerns will be taken seriously and dealt with appropriately and policies and procedures are in place to protect the residents from the threat of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is included in the Statement of Purpose and the Service Users Guide. A book is kept for recording complaints and only one complaint had been recorded since the last inspection (see ‘Staffing’). No complaints have been referred to the Commission about this service since the current providers took over the business. Feedback from questionnaires completed by relatives of the residents indicated that they have confidence in the manager to resolve and complaints or concerns that they may have. The Annual Quality Assurance Assessment completed by the registered manager identifies that written policies and procedures about safeguarding and protecting the residents from abuse are in place and the registered manager said that all of the care staff had received training on the Protection of Vulnerable Adults. 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. With the exception of the bathrooms, which do need attention, the residents are provided with well presented and comfortable accommodation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 1 – 4 Windsor Drive is a row of four semi-detached bungalows. Each of the bungalows has a lounge, kitchen, bathroom, three bedrooms and an additional room. The additional rooms are used as an office, a sleeping in room, a sensory room for the residents and an activities room. Each pair of bungalows is connected through a shared laundry room. Each of the four lounges was seen to be clean, well presented and large enough to accommodate the three residents who share it and, where 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 19 applicable, their mobility aids. The four kitchens are all fully equipped and large enough to provide an eating area. Each of the residents has their own bedroom and all of the bedrooms were seen to be clean and personalised to reflect the interests and personalities of the individuals. All four of the bathrooms are showing signs of wear and tear and would benefit from refurbishment. Each of the bathrooms has a tracker hoist but two of these are broken and the registered manager said that they were beyond repair. Mobile hoists are available to enable the staff to help the residents to get into and out of the baths. There facilities available to enable the residents to take a shower. Toilets with toilet frames are available in the bathrooms and each of the bungalows has a separate toilet. The laundry facilities meet the needs of the home. The four bungalows have individual front gardens and share a very pleasant back garden, which is designed to attract wildlife. 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is adequate. Feedback from surveys indicates that the staffing levels are not always high enough to meet the needs of the residents. Although staff training is provided, the provision of training in areas which relate directly to the provision of care for people with learning disabilities is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a lower than average staff turnover and some of the staff have worked at the home since it was first registered (under different ownership) eighteen years ago. This has provided good continuity as some of the residents have also lived at Windsor Drive for eighteen years. An inspection of staff recruitment records provided evidence that safe practices are being used to recruit new staff. New staff are required to complete a ‘day one’ familiarisation programme and this is followed up with by twelve week induction training programme. 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 21 Some of the relatives and professional people who completed and returned surveys for the Commission stated that the staffing levels were not always high enough to meet the assessed needs of the people who use the service. The complaint that had been recorded in the homes ‘Complaints Book’ was made by healthcare professionals and also raised concerns about the staffing levels. The staff rota was inspected and from the information provided the care staffing levels fluctuate throughout the day (7am to 10pm), but do not fall below providing a minimum of one care worker to three residents. The care needs of all of the current residents, who have physical disabilities and learning disabilities are high and the registered manager does need to continually monitor the staffing levels to ensure they are high enough to meet their assessed needs at all times. Over night care (10pm to 7am) is provided by two waking night staff (one in each pair of bungalows) and one person sleeping in and on call. A housekeeper is employed for between twenty-four and thirty-two hours each week and an activities organiser is employed for twenty hours a week. The home has been proactive in encouraging the care staff to gain National Vocational Qualifications. The registered manager has achieved her Registered Managers Award (NVQ Level 4), one of the deputy managers has an NVQ at Level 4, the other deputy manager and five of the care staff have completed an NVQ at Level 3 and three of the care staff have completed an NVQ at Level 2. The staff training records showed that most of the staff had received training in the health and safety related areas including Fire Safety, Manual Handling, First Aid, Health and Safety & Infection Control and that this training was regularly updated. The provision of staff training courses in areas specific to the provision of care of people with learning disabilities was found to be very poor. This means that although the manager and staff are providing a good standard of care, they may not have up to date knowledge of the developments that have taken place in terms of methods of communication, active support models, social role valorisation, person centred planning and dealing with behaviour that challenges services. 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. The residents benefit from living in a well managed home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although 1 – 4 Windsor Drive has operated as a care home for many years, it was registered as a new service in December 2008 because of a change of the ownership of the business to Guinness Care & Support Limited. The registered manager is very experienced and was observed to have built up a good relationship with the residents and staff, most of whom she has worked with for many years. She has gained her Registered Managers Award 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 23 (National Vocational Qualification at Level 4) and qualified and worked as a nurse before becoming the manager of a residential care home. Records were seen to demonstrate that the home is carrying out quality assurance/quality monitoring to gain feedback from the relatives of residents and people who are involved with the residents in a professional capacity. This information is being used to implement changes to the way the manager and staff work with the service users. In addition to this the staff are given the opportunity to comment on the day-to-day running of the home through regular staff meetings. The registered manager said that since taking over the control of the home Guinness Care & Support Limited have updated the policies and procedures and that she and the staff plan to familiarise themselves with these during team meetings. All of the new policies and procedures are accessible on the computer and the registered manager said that she was in the process of printing these off to make them more readily accessible to the staff. 1-4 Windsor Drive DS0000071097.V363575.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 2 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 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement The statement of terms and conditions contained in the Service Users’ Guide must include the amount and method of payment of fees and every resident must be given a Service Users’ Guide. The care staffing levels must be reviewed to ensure that they are high enough to meet the assessed needs of the current residents. Timescale for action 10/09/08 2. YA32 18 10/07/08 3. YA35 18 Arrangements must be made to 10/12/08 enable the manager and staff be receive training that is specific to meeting the needs of people with learning disabilities. 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 Good Practice Recommendations DS0000071097.V363575.R01.S.doc Version 5.2 Page 26 1-4 Windsor Drive 1 Standard YA1 The information included in the Statement of Purpose about the range of fees and extra charges should be amended to provide accurate information for prospective residents and their representatives. The residents and their families or independent advocates need to be actively involved in their care planning and reviews, which could be more person centred. If decisions are made for individual residents records should be kept to show why. The residents should be given the opportunity to take annual holidays away from their home. The residents should be helped and encouraged to be actively involved household chores such as cleaning and cooking. The manager should ensure that communication between the staff and between the home and residents relatives is consistently good. The bathrooms would benefit from refurbishment and the broken overhead hoists in two of the bathrooms should be replaced or repaired. 2. YA6 3. 4. 5 YA7 YA14 YA16 6 YA19 7 YA24 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 1-4 Windsor Drive DS0000071097.V363575.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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