Inspection on 16/01/07 for 117A & B Hitchin Road

This inspection was carried out on 16th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

117A & B Hitchin Road 17/02/09

117A & B Hitchin Road 09/01/08

117A & B Hitchin Road 07/02/06

117A & B Hitchin Road 16/08/05

117A & B Hitchin Road 07/03/05

117A & B Hitchin Road 07/03/05

117A & B Hitchin Road 07/03/05

117A & B Hitchin Road 07/03/05

117A & B Hitchin Road 30/09/04

117A & B Hitchin Road 30/09/04

117A & B Hitchin Road 30/09/04

117A & B Hitchin Road 30/09/04

117A & B Hitchin Road 01/12/03

117A & B Hitchin Road 01/12/03

117A & B Hitchin Road 01/12/03

117A & B Hitchin Road 01/12/03

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Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 117A & B Hitchin Road Shefford Bedfordshire SG17 5JD Lead Inspector Mr Ian Dunthorne Unannounced Inspection 10th January 2007 10:00 117A & B Hitchin Road DS0000015002.V326086.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 117A & B Hitchin Road DS0000015002.V326086.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. 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 117A & B Hitchin Road Address Shefford Bedfordshire SG17 5JD 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) 01462 850022 01462 850689 jeff.smith@hft.org.uk www.hft.org.uk Home Farm Trust Mr Jeffery Smith Care Home 12 Category(ies) of Learning disability (12) registration, with number of places 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: 117 A B Hitchin Road is one of five registered care homes within Bedfordshire managed by Home Farm Trust. HFT are a nationwide provider for people with learning disabilities. The home is situated on the outskirts of Shefford, which has a number of facilities including shops, pubs, restaurants and a library. The home provides its own transport in the form of two domestic scale vehicles. There is ample parking space, shared with the organisations headquarters/day care facility, which is adjacent to the home. The building has been divided into two units - Oncemore House and Applewood House, and provides accommodation for 12 adults with learning disabilities. Each unit has been designed to accommodate six adults, with separate and independent sleeping and communal facilities. Each has its own lounge, dining room, kitchen, bathing and toilet facilities, and individual bedrooms for all service users. There are separate external doors to access each unit, and they are also linked internally, through the upstairs office/staff sleeping in area. Outside, there is a shared laundry room and a large garden. Information relating to the homes range of monthly fees is available. It is included within information provided about the home and individual service users contracts. However the information does not include or specify any additional charges that may be made, that are not included within the fee. 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 hours during the afternoon and early evening and it was unannounced. Prior to the inspection time was taken to review the information gathered since the last inspection and plan this inspection visit. This report also includes feedback from relatives and service users obtained from postal surveys. The inspection included a tour of the communal areas and several bedrooms, inspection of certain records, discussion with staff and the manager, discussion with service users and observation of the routines of the home. No relatives were available during the inspection to speak with. The method of inspection was to track the lives of several service users. This was done by speaking to them about the service they receive, observing their life in the home, talking to staff and reviewing their records. What the service does well: What has improved since the last inspection? One senior staff member said that education and leisure activities had improved during the week and evenings and evidence supported this. The home has developed systems for asking for the views of service users and others about what they think of the home and any suggested ideas for improvement. Then producing a plan, showing how they will act upon those views and carry the plan out 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 6 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. 117A & B Hitchin Road DS0000015002.V326086.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 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service User Guide were good, providing service users and prospective service users with details of the services the home provides, enabling an informed decision about admission to the home. EVIDENCE: All the respondents to the surveys sent to the service users, said that they felt they were given enough information about the home to make an informed choice about whether to live there. The homes service user guide was available in a suitable format for some of the service users intended and provided information to enable prospective service users to make an informed choice about where to live. The basic fee charged and extra support costs charged per hour were included within the information, however it did not include the cost of any ‘extras’ that may not be included within the fee. The homes last inspection report was available within the home, but only accessible upon request; some staff were not aware that this was a public document and should be made available to service users and their families. There was evidence that the home had assessed the needs of a prospective service user and demonstrated that the method and system for doing so 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 9 provided a satisfactory form of assessment. The method of assessment involved the service user, the family and other individuals referred to as part of the service users care management process. Evidence from the postal surveys sent to service users, identified that they were given the opportunity and some undertook, trial introductory visits to the home before making any final decision about moving there. Information regarding trial visits was also included within the homes’ service users guide under ‘moving in’ section, describing the benefits and purpose of this. There was evidence that the service users whose lives were tracked had written contracts with the home, which included a statement of the terms and conditions. There was evidence that the home had introduced contracts in a format appropriate for the needs of most of the service users. 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user plans contained satisfactory information, however further development was needed to ensure both the plans and risk assessments were reviewed and updated at regular intervals. To ensure they accurately reflected service users changing needs and associated risks to enable the home to meet those needs and minimise risk to service users. EVIDENCE: A sample of the service user’s plans and supporting documentation were examined and found to contain suitable and sufficient information to help meet their changing needs and personal goals were identified and reflected in their individual plan. There was evidence that the plans had been reviewed, although this had not been achieved at suitably regular intervals. In addition annual reviews of the residents needs and subsequent service user plans had been held, which involved the service user, the manager, keyworker, family 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 11 member and when necessary, advocate. The plan was not made available in a format the service user could understand. It should be noted that as part of the homes approach to develop their person centred planning principles, they are in the process of introducing a new service user plan & assessment tool system called ‘SPARS’. They were chosen by the provider, HFT, as one of its homes to pilot this system on a trial basis. This system will meet the requirement set for this standard at the last inspection of this service. There was evidence from speaking with service users and records examined that service users were assisted as necessary to make decisions about their daily lives. Service users were supported by staff to participate in an advocacy service provided if they wished. Staff were observed communicating in ways appropriate to each individual service user, to enable them to make an informed decision in a way the service user could understand. There were risk assessments in place as part of the homes risk assessment strategy to enable service users to take risks supported by staff, however some had limited value because several of those examined had not been regularly reviewed. The home had identified on some risk assessments that they should be reviewed in three months, however this had not been done and they were reviewed at six months intervals instead. Several risk assessments in place were compiled in 2003 and there was no evidence that they had been altered or updated since that time. None of the risk assessments examined had been signed by the staff member completing it, in the space provided on the form. 117A & B Hitchin Road DS0000015002.V326086.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, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided satisfactory opportunities for education & social activities, however this was limited to weekdays only and further development was required to extend the opportunities to include weekends, as a result service users social activity choice can sometimes be restricted. Suitable equipment to monitor the weight of some service users was not provided; therefore those service users were placed at risk, as their nutritional healthcare needs could not be adequately assessed. EVIDENCE: The home supported service users to attend college and many were also supported by the home to regularly visit a local resource centre, which provided planned educational and training activities, during the day and evening. 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 13 Service users were supported by the home to attend church when they wished to. The home demonstrated that it had a flexible approach to supporting service users inside and outside of the home during weekdays and evenings. However it was limited to those times and there was evidence from speaking to staff and feedback from service users surveys that this did not extend to weekends. In both forms of evidence, the reasons given for this were described as due to a lack of resources and staff at weekends. There was evidence that the home supported service users to maintain family links and friendships inside and outside the home, in accordance with their wishes. This evidence was supported by responses within service user surveys. Staff were observed knocking on service user’s bedroom doors before entering and waiting to be invited into their bedrooms. Those service users who wished to were supported to keep their own room keys. Service users responsibility for housekeeping tasks was specified within individuals’ service user plans and generally within the homes’ service user guide. Service users were observed during a mealtime enjoying well prepared and presented, home cooked and appetising food in suitably sized portions. There were no set mealtimes as such, as the service users preferred the flexibility and this also suited their individual evening activities. Service users were observed being supported by staff to clean and tidy up after the meal. Some service users nutritional needs were being monitored, staff members spoken to were able to explain why this was. However the home was unable to meet the nutritional needs of some service users with a physical disability fully, because suitable equipment to monitor their weight was not provided. This subsequently prevented the home from assessing the risk factors associated with any weight change by some service users with physical disability needs. 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems for the administration of medication were satisfactory. However further development was needed to ensure that records of administration completed & maintained by the home were clear and accurate, to safe guard the health and well being of service users. EVIDENCE: Service users spoken to said they enjoyed living at the home. All respondents to the service users surveys said that they were treated well by staff. There was evidence that service users received additional specialist support and advice from people outside the home such as occupational & speech therapists when needed. Service users appearance reflected their personality, as they were able to choose, some with support, their own clothes, make up & hairstyles for example. During a mealtime one service user was observed demonstrating how pleased they were with the result of their new nail varnish. 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 15 There was evidence that the home accessed outside healthcare professionals and services as required; in order to support and meet the healthcare needs of the service users. Although medical practitioners visits were not always clearly documented by the home. A variety of healthcare monitoring charts were in use. The home had ensured that care staff were trained in medication and the procedures implemented suggested that service users safety was being maintained in most areas. Staff observed administering medication to service users appeared competent and confident. Further development was required in some areas of medication administration recording to ensure that accurate records were kept. The home had good death and dying policies. The home had discussed service users wishes in the event of terminal care and death; service users family and friends had been involved in planning for this. This information had been documented. 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for protecting service users were good and the home maintained an effective approach to complaints within a satisfactory system. This helped to ensure service users were protected from abuse and to feel that they views were listened to and acted upon. EVIDENCE: The home had a satisfactory complaints procedure that ensured service users felt their views were listened to and acted upon. The complaints procedure was produced in a format appropriate for service users to understand and access. There had been three internal complaints since the last inspection all between service users, evidence demonstrated that they were managed in a way that ensured the service users involved were listened to and their views acted upon which complied with their policy and evidence of the process was recorded. The home had a Protection of Vulnerable Adults (POVA) policy in place, which included whistle blowing and staff spoken to demonstrated they were aware of the procedure. Most staff had also attended abuse awareness training, which included POVA, POVA training was also included and formed part of the homes induction process for staff. Since the last inspection there had been one notifiable incident in accordance with the POVA policy and guidance, which was reported to CSCI at the time. 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 17 Evidence examined, supported a process that had been followed to safeguard and protect service users. The homes policies and practices regarding service users money and financial affairs were generally satisfactory and protected service users from abuse. There was evidence that the home was about to introduce a revised policy for the management of service users money and finance, to improve and ensure robust practices were followed. 117A & B Hitchin Road DS0000015002.V326086.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, 26, 27, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were identified risks and a poor standard of décor in some areas of the home and the ‘tiredness’ in some areas of the building detracted from the homeliness of the environment. There was little evidence of improvement through maintenance or future planning. EVIDENCE: The home provided a purpose built, environment for service users. The home prevented safe access to its wheelchair using service users, as there was no level access from the main road to the home. Staff had to risk the safety of the service users and themselves, by practising an unsafe manoeuvre to position the wheelchair up the kerb. An immediate requirement was issued, as the kitchen sink hot water in 117A house exceeded a safe regulated temperature and placed service users at risk of scolding themselves. 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 19 Respondents to the service user surveys identified some areas of the home as needing some repair and maintenance attention, this was supported by several observations during this inspection. One service user said that they had everything they needed and wanted in their bedroom. Another service users bedroom was observed to reflect their needs and lifestyle. All rooms were single occupancy. Service users spoken to were clearly happy with their individual bedrooms and they had free access to them, one service user said they had chosen the decoration themselves with the support of their family. However one service users bedroom was observed to have peeling wallpaper due to the dampness of the wall. It was evident that this service user had been waiting for some time to have this addressed by the home. A requirement was set at the last inspection stating that ‘All toilets and bathing facilities must have sufficient floor space to ensure the safe manoeuvre of service users.’ It was disappointing to observe that this requirement had still not been met by the home. The home failed to meet the individual needs of its service users with physical disabilities by providing them with specialist equipment. See ‘Lifestyle’ section of this report. The home appeared clean and generally free from offensive odours, service users, care staff and night staff were responsible for ensuring this was maintained. However some communal toilets and bathrooms within the home, had a communal towel in as the only facility to dry your hands on after washing them. This was not an effective infection control system that was consistent throughout the home, because in the remaining facilities disposable paper towels were provided. In addition a communal bathmat was in place in one bathroom, which also presented a slip and trip hazard. 117A & B Hitchin Road DS0000015002.V326086.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, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staff training were satisfactory. However further development was needed to ensure that staff received training in service users specialist needs, enabling the opportunity for those needs to be understood and met. EVIDENCE: Staff spoken to identified varied training which they had undertaken at the home and this was supported by evidence in their training records. Although there was limited evidence that training in some service users specialist needs had been provided. For example, three service users were diagnosed with dementia, however there was insufficient evidence to support adequate staff training to meet service users needs in this area. The percentage of staff qualified at nvq (national vocational qualification) level 2 or 3, fell just below the minimum required level of 50 . Staffing level numbers within the home were maintained to meet the appropriate ratio based upon the needs of the service user; to maintain this 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 21 there was regular use of agency staff, particularly at weekends. However the home was provided with regularly agency staff, which helped to provide a consistent service for service users. Staffing level numbers fluctuated based on how many service users were in the home, they sometimes reduced at the weekends particularly if several service users had gone away. However this then impacted upon service users social activities at weekends, see ‘Lifestyle’ section of this report. Staff files that were examined, demonstrated that the home had obtained satisfactory checks and clearances on staff before their commencement. Although some staff records employed some time ago were held centrally and not in the home. They were however accessible which the manager was able to demonstrate. The same staff that were employed over four years ago did not have any evidence to support an induction on their files. There was no structured training & development plan for each staff member in place, however the acting manager explained that ‘personal profile passports’ will be introduced in the future, which are intended to meet this requirement. The acting manager provided evidence of a training analysis format for the home, which she explained once introduced should formulate the basis of a training & development plan for the home. Staff spoken to and records examined, provided evidence that staff received regular supervision. 117A & B Hitchin Road DS0000015002.V326086.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, 38, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some aspects of the homes health & safety and safe working practice procedures needed further development to ensure service users & staff would be protected from the risk of harm. EVIDENCE: The registered manager is currently absent on a long-term basis from the home. As a contingency plan, an Acting Manager has been temporarily appointed via internal promotion, Christine Anderson. Christine had achieved qualifications in both NVQ level 2 & 3 in care. 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 23 The acting manager was observed to communicate effectively with both service users and staff and appeared approachable. Service users and staff who were spoken to supported this view. The home had an inclusive atmosphere. The acting manager of the home maintained an effective leadership ethos that both service users and staff were able to benefit from. The acting manager said that regular meetings were held with service users, their family and friends of the home, although evidence of this was not examined. A staff consultation group meeting was observed advertised on a notice board in a staffing area. Staff spoke of regular staff meetings held within the home. The home had developed a quality assurance and monitoring system, from which the home had developed an action plan from the information it had collected from several sources. There was evidence that the home had begun a cyclical system of regularly monitoring and reviewing service users views, amongst others. However further development was needed to ensure that action plans associated with this process are given specific time scales or target dates. Some aspects of the homes health & safety safe working practices, required some improvements to protect service users from potential risk or harm. See ‘Environment’ section of this report. Various records were examined to support adequate compliance with the following safe working practices, regarding health & safety. 117A & B Hitchin Road DS0000015002.V326086.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 3 5 3 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 1 25 X 26 2 27 1 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 2 3 3 X X 2 X 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 15 (1) Requirement Timescale for action 31/03/07 2. YA9 3. YA13 13`(4) (a), (b), (c) & 15 (2) (b) 16 (2) (m) All care plans must be reviewed on a regular basis and changes made where necessary. Previous timescales: 30.09.05, 30/04/06. Risk assessments must be 31/03/07 reviewed by the home at appropriate and agreed intervals. The home must support service users (as far as practical) to engage in local, social & community activities when they wish to and in accordance with their needs. There must be suitable equipment within the home to monitor the weight of each service user including those with physical disabilities, to ensure that nutritional risk factors and needs can be assessed. Arrangements must be made to ensure the safety of the service users are maintained which will not expose them to excessive hot water or hot surfaces that could scald. This is in particular reference to excessive hot water and uncovered radiators. DS0000015002.V326086.R01.S.doc 30/04/07 4. YA17 12 (1) (a) & 23 (2) (n) 30/04/07 5. YA24 12 (2) 13(4) (a) 23/01/07 117A & B Hitchin Road Version 5.2 Page 26 6. YA27 23 (2) (a) 7. YA32 YA35 18 (1c,i) (Confirmation received by the commission that these have been actioned) Previous timescale: 14/07/06 This was met in part regarding the radiator covers in specific areas, however an immediate requirement was issued regarding excessively hot water. (Confirmation received by the commission that this has been actioned) All toilets and bathing facilities 30/05/07 must have sufficient floor space to ensure the safe manoeuvre of service users. Previous timescale: 30.10.05, 30/05/06 Training must be provided for 30/04/07 staff, which is appropriate for the work they are to perform. 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. 3. 4. Refer to Standard YA1 YA1 YA6 YA19 Good Practice Recommendations The home should ensure that information about the home including service user contracts & the service user’s guide, are available in formats suitable for each service user. The home should ensure that a copy of the most recent inspection report is made available to both service users and their families. Arrangements should be made to ensure that service user plans are made available in a language and format that the service user can understand. Accurate records should be maintained regarding the health and physical needs of service users. 117A & B Hitchin Road DS0000015002.V326086.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 117A & B Hitchin Road DS0000015002.V326086.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!