Inspection on 23/01/07 for 130 Whitworth Road

This inspection was carried out on 23rd 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

130 Whitworth Road 09/08/07

130 Whitworth Road 10/05/05

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 08/07/2008.

CARE HOME ADULTS 18-65 Whitworth Road (130) 130 Whitworth Road Swindon Wiltshire SN25 3BJ Lead Inspector Pauline Lintern Key Unannounced Inspection 23rd January 2007 10:00 Whitworth Road (130) DS0000061295.V319826.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 Whitworth Road (130) DS0000061295.V319826.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. Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitworth Road (130) Address 130 Whitworth Road Swindon Wiltshire SN25 3BJ 01793 651678 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) londonroad@tiscali.co.uk Milbury Care Services Limited Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2005 Brief Description of the Service: The home is one of a number of homes owned and operated by Milbury Care Services. Situated in a residential area of Swindon the property is in keeping with other houses in the areas. The home is close to local bus routes and local amenities and within easy access to Swindon town centre. The service accommodates a maximum of four service users whose needs can be challenging. Staffing arrangements are determined by the needs of service users and at the time of the inspection there was a minimum of two staff on duty at any one time. The home provides waking night staff in addition to one member of staff sleeping in. The philosophy of care is underpinned by John OBriens five accomplishments with the emphasis of care to promote independence and support service users enjoyment in experiencing the wider community. Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took place over five and a half hours. The designate manager was present during the inspection. There was four staff on duty in the morning and three in the afternoon. There is a sleeping in staff and one waking night staff member during the night. During the inspection the operations manager visited the home to carry out the monthly audit. As part of the inspection process records were sampled. These included two care plans, risk assessments, staff recruitment records, medication records, health and safety records and staff supervisions. The inspector had the opportunity to meet with three service users and was able to obtain their views on the service provided to them at Whitworth Road. Four survey forms were sent out to relatives and four to service users prior to the inspection. Two relatives forms were returned to us and three were returned from service users. Surveys returned to us were generally positive about the service. At the end of the inspection the inspector was able to feedback her findings to the manager. What the service does well: What has improved since the last inspection? Risk assessments and care plans are now in place for each individual living at the home. Care plans demonstrate how service users’ holistic needs are to be met. Care plans and risk assessments are now kept under review. There is now a policy in place for cross gender working when delivering personal care. Care plans now include guidelines on the use of‘as required’ medication and any refusals are recorded. Although there are not clear guidelines for the use of ‘homely’ remedies when used with ‘as required’ medication, the manager confirmed that in this instance they always seek guidance from the general practitioner. The recording of administered medication appears to be correctly recorded now. The fire logbook was available for examination at this inspection. Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 6 There is now a complaints procedure in a format suited to the needs of the service users. 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. Whitworth Road (130) DS0000061295.V319826.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 Whitworth Road (130) DS0000061295.V319826.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 and 2 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is a service user guide and statement of purpose available to provide information about the service, however they both need updating to ensure that the contents are current. Service users are assessed prior to being offered a place, however one service user had limited information on their case file. EVIDENCE: The manager confirmed that the service user guide and the statement of purpose are in the process of being updated. Three out of three surveys returned to us by service users state that they were asked if they wanted to move to the home and that they had received enough information about the service before making a decision. Where possible trial visits can be arranged before a new person moves into the home. One service user said that they had visited once before they moved in and another person commented ‘ I’m glad it’s not a trial period now and I am happy to stay here for life’. One of the files examined showed that a full assessment of needs had been completed prior to moving into the home. This included information on Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 9 communication needs, activities, nutritional needs, mobility, personal care and healthcare needs. There was a pictorial service user guide and a copy of the service agreement. There was also an assessment completed by the funding authority. The second file sampled had limited information in it. The manager explained that this was the only information received from the previous placement. There was a copy of the service user guide, which included the service users rights whilst living at the home and a breakdown of the fees charged. Neither service user guide had a copy of the last inspection report and one did not have a copy of their contract in it. The manager needs to confirm in writing to each service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of their health and welfare. The manager confirmed that she would action this. Whitworth Road (130) DS0000061295.V319826.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Each service user has an individual care plan. Service users are encouraged to make decisions about how they live their lives. The management of risks takes into account age and specialist needs. EVIDENCE: Two care plans were sampled as part of the inspection process. They contain information on leisure, communication, access to education, domestic skills, family and social needs, finances, life changes, mobility, physical wellbeing and psychological needs. There is evidence, which demonstrates that care plans are being kept under review. Files contain personal details with pictures and photographs in them. There is a statement that relates to access to the service users file, which informs the person that the file belongs to them. Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 11 Feedback from relatives in their comment cards say that they are kept informed of important matters affecting their relative/friend, one said that they were not kept informed. Three out of three service user surveys state that they are able to make decisions about what they do each day. There are guidelines on how staff can support people to make choices about their life. Each service user is offered the choice of their own menu for the week. One service user told the inspector that they choose the clothes they wish to buy but staff members support them to go shopping. Risk assessments are completed and kept under review. Where a risk has been identified and this has resulted in a restriction to the service user this has been discussed with the service user, their care manager and family and is documented in their care plan. Staff members report that the home does not have a key worker system in place however all staff members work with each of the service users. There are guidelines and procedures in place for managing any aggressive behaviour, which may be displayed by service users. Staff confirm that techniques in place work well and they are usually able calm a situation down before it escalates. Staff receive regular training in physical intervention techniques. Whitworth Road (130) DS0000061295.V319826.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users have the opportunity to participate in appropriate activities and access the community. Contact with family and friends is encouraged. Service users are respected as individuals. Meals are varied and chosen by the service users. EVIDENCE: One service user reported that they attend college three days a week, which they enjoy. Included in the course are stress management, Thai- chi, art and pampering days when they have facials and manicures. Another person told the inspector that they had been to the Metcalf centre in Chippenham where they had ‘been sewing, making a mat today’. They added that they had enjoyed the lunch and had their favourite fish and chips. Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 13 One service user reported that they enjoy visits to the local pub with staff support. One care plan shows that the service user’s goal is to ‘go out on my own and to also have a night out on the town’. The manager explained that they have now found a suitable disco, which they hope to be able to access in the future. Other activities that take place are trips to the cinema, bowling, theatre trips, watching DVD’s and the soaps on television and going to the arboretum. One service user enjoys watching horse racing and staff will support them to attend a nearby course and will support them to ‘collect their winnings’. Once a month the service user will visit the local dog track with a friend. The manager confirmed that the home would often arrange to meet up with service users from another nearby Milbury home for special occasions. She confirmed that they all got together for a Christmas meal, which everyone seemed to enjoy. One service user confirmed that they have been discussing where they would like to go on holiday this year. They explained that they are going with another service user from the house as ‘we get on well and I like them, they’re funny and make me laugh’. They have chosen to go to Butlins holiday camp. The manager explained that one service user would prefer to go on their own with two staff but they have not yet decided on a venue. Family and friends are welcome at the home. Both surveys returned from relatives/friends confirm that they are able to see their relative in private if they wish. One person explained that their mum visits the home once a week, which they look forward to. Another service user meets a friend in town once a week. During the inspection staff members were observed being respectful towards service users. One service user survey states ‘ Staff are nice to me’ and the remaining surveys state that staff ‘always’ treat them well’. Service users have the opportunity to choose their individual menu for the week. There is a notice board with each person’s weekly menu shown. One service user told the inspector that ‘fish and chips and pizza is my favourite’, another person said that they would like to make an apple pie in the future and staff responded positively saying that they would access a recipe for them. Staff monitor the menus to ensure that the service users’ nutritional needs are being met. Whitworth Road (130) DS0000061295.V319826.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 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Personal support is offered in a way that service users prefer. Both physical and emotional needs are met. Medication policies and procedures are in place however some practices relating to the administration of medication could put service users at risk. EVIDENCE: Care plans detail how a person’s personal care should be delivered and stipulate any specific support requirements. One person asks that ‘staff ask me if I would like a bath or if I would prefer to have a shower’. Another reminds staff members to knock on their bedroom door before entering. Health care professionals such as the community nurse and the consultant psychiatrist visit the home regularly to ensure that service users health needs are being monitored. Each service user is registered with a local general practitioner. The manager explained that they are in the process of updating individual health plans for each person. Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 15 The home have developed a ‘cross gender’ protocol following a requirement set at the last inspection. Each service user has a medication risk assessment in place, which has recently been reviewed. The home’s policy is that only staff who are trained to do so, may administer medication to a service user. There is information available on service user’s conditions to ensure that staff have a sound knowledge of the service users health requirements. All ‘as required’ (PRN) medication is recorded when administered and there is an explanation as to why it was given. Any refusals are also recorded. The manager explained that they have a medication checklist where two staff members sign in all medication when it is delivered to the home. Medication is stored securely in a locked cabinet. It was of concern to the inspector that on checking the medication it appeared that one service user had not been administered their morning medication by lunchtime. The manager reported that this had been an oversight and was not general practice. She confirmed that she would be vigilant in the future to ensure this does not happen again. It was recommended that the manager ensure that staff complete ‘in-house’ refresher training on the administration of medicines on a regular basis. Whitworth Road (130) DS0000061295.V319826.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 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users feel that they can raise any concerns or complaints, which they may have. Where possible service users are protected from any form of abuse. EVIDENCE: Service users confirmed that they know how to make a complaint if they wished to. One service user commented ‘If I was concerned or worried I would ring my social worker’. Both of the relatives surveys returned to us also report that they know how to make a complaint but to date have not needed to. The manager reports that there have been no complaints made since the last inspection. Each service user guide has a copy of the complaints procedure and provides the telephone number of Milbury complaints department. The procedure is in a pictorial format. The complaints policy states that complaints will be responded to within a 28-day timescale. The manager confirmed that any complaints made would be sent to the head office. It is recommended that the manager keeps a record of any complaints at the home to ensure that she can monitor if there are any trends or patterns arising. Training of staff in the area of protection is regularly arranged by the home. The Protection of Vulnerable Adults (POVA) is covered in the home’s induction Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 17 training to ensure that all new staff has an understanding of ‘safeguarding’ adults. Staff members who spoke to the inspector explained the action they would take if they suspected any form of abuse was taking place. They confirmed that they have a copy of the Wiltshire and Swindon’s guidance ‘No Secrets’ and understand the ‘whistle blowing’ policy. Staff members have the opportunity to complete the ‘Learning Disabilities Framework Award (LDAF), which also includes abuse awareness training. Whitworth Road (130) DS0000061295.V319826.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 and 30 Quality in this outcome area is good Service users live in a homely, comfortable and safe environment. The home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The premises are well maintained and in good decorative order. Furnishings and fittings are of a good quality. The home provides a safe environment, which is bright and cheerful. All radiators are covered to protect service users and there are restrictors on the windows. Each service users room has been personalised. One service user commented “I like my room and I have lights (sensory) in there”. Another person told the inspector that they have “two fishes’ in their room. The manager explained that all service users are offered a key to their bedroom however only two people choose to use them. Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 19 At the time of the inspection the home was clean and tidy with no offensive odours. Bathrooms and toilets were clean and hygienic. There is a separate laundry, which houses the washing machine and tumble drier. All toxic materials are securely stored within the laundry room. Data is gathered for all toxic materials and is kept in a file for staff to access. Staff members confirm that the home uses red alginate bags for transporting soiled laundry to the washing machine. There is evidence that staff attend training in infection control and staff report that they have access to protective clothing when required such as aprons and gloves to minimise the risk of cross infection. Whitworth Road (130) DS0000061295.V319826.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 and 36 Quality in this outcome area is adequate Staff have the competences and qualities to meet service users needs. The home’s recruitment policy and practices generally protect service users however many of the recruitment records are not being kept at the home, which could potentially place service users at risk as the manager does not have easy access to the relevant information. Staff members attend regular training. Staff supervision does take place but the frequency of the meetings needs to be monitored. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff members were observed interacting with service users and ‘chatting’ about various topics. Services users appeared to be relaxed and comfortable in the staff members company. At the time of the inspection the manager reports that they have two staff that hold a current National Vocational Qualification level 2 and one staff member holds a current first aid certificate. Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 21 The staff rota shows that generally there are three staff on each shift excluding the manager, sometimes four. During the night there is one waking night staff and one member of staff ‘sleeping in’. One staff member commented “there are plenty of staff on duty, which is good as we can take service users out”. Both relatives survey forms returned to us agreed that there is sufficient staff on duty at the home. The manager confirmed that they use one regular bank member of staff, which provides consistency for the service user and that they do not use agency staff at the present time. A positive feature of this service is that the staff are recruited from a variety of ethnic and social groups to reflect the local population. As part of the inspection process three staff recruitment records were sampled. Many records were not available for inspection including staff contract, evidence of checks with the Criminal Records Bureau (CRB) and other recruitment records. The manager explained that they are held at the head office. It is a requirement that all records, as stated in schedule 2 of the Care Homes Regulations 2001 are kept at the home and are available for examination if requested. The manager confirmed that she would obtain a list of all staff members and proof that they are in receipt of a valid CRB check for the inspector. All CRB numbers were sent through to the inspector as requested. The manager explained that one member of staff has mislaid her CRB certificate and is in the process of obtaining a replacement, however Milbury have evidence that there was a CRB check completed prior to them commencing employment. One staff member reported that since commencing their employment “Milbury have given me lots of training”. The training programme shows that staff members have the opportunity to attend training in Fire, manual handling, health and safety, infection control, first aid, person centred planning, medication, POVA, epilepsy, autism, diabetes, managing behaviours, O’Briens accomplishments, supervisions and non-violent crisis intervention (NVCI). Staff members report that they have one to one supervision with their line manager. Records show that the frequency of staff supervisions needs to be monitored to ensure that staff receive at least six formal supervisions annually. Minutes from the team meeting on 5/10/06 show that discussion took place on fire drills, activities and how to respect service users rights. Staff members confirmed that they attend team meetings. Whitworth Road (130) DS0000061295.V319826.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 and 42 Quality in this outcome area is good The home is well managed. The quality of the service is periodically reviewed. Where possible service users health and safety and welfare is protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home has yet to attend a ‘fit person’ interview with the Commission to enable her to become registered. She confirmed that she would be submitting her application to us in the near future. The manager has recently completed her NVQ award level 4 and has now applied to begin her Registered Managers Award (RMA). She has already been awarded the NVQ level 3. The manager has an ‘open door’ policy, and confirmed that staff members know that she is available if they need her. It was noted that the daily communication book had an entry from the manager thanking all of the Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 23 staff team for working hard, which indicates that she appreciates their input and feeds this back to them. There was a copy of the Annual Service review for this service for 2006/07. The manager explained that the results from this audit then go to form the development plan for the home. She confirmed that questionnaires are sent out to staff members and relatives. The operations manager on a monthly basis completes regular audits. This includes feedback from staff members and service users. It is recommended that the manager organise regular service user meetings, which are recorded. This will provide further opportunities for service users to take part in the running of the home and enable them to share their views. Health and safety records are routinely completed. Staff receive all relevant health and safety training and attend refresher training as required. The manager reports that the waking night staff complete checks on the fridge/freezer temperatures, whilst day staff check and record the temperatures of the water to minimise any risks to service users. There are regulators on all taps. Records show that there are regular fire drills for staff and service users (the last one being on 22/01/06). One service user confirmed that they knew the procedure to follow if the fire alarm was activated. All checks relating to fire fighting equipment and lighting systems have been regularly completed and recorded. The fire risk assessment is in need of being updated. The accident book was examined and found to be in order. The last accident recorded was dated 16/11/07. The manager reported that once accident forms are completed they are sent to head office to be audited. It is recommended that the manager also audits the accident forms on a monthly basis to see if any patterns arise. One service user told the inspector that they have all been provided with a torch for their bedrooms in case of power failure. At the time of the inspection the manager was in the process of developing an ‘emergency contingency box’, which contains other items for use in an emergency. Whitworth Road (130) DS0000061295.V319826.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 2 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 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 X 3 X X 3 X Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 25 YES 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. 1 Standard YA1 Regulation 5(1)( c ) (d) Requirement Timescale for action 23/03/07 2 YA2 14(1)(d) 3 YA1 6(a)(b) The registered person must provide a Service User Guide, which shall include a copy of the last inspection report and a standard form of contract. The registered person shall 23/03/07 confirm in writing to each service user that the care home is suitable to meet the needs of the service user. The registered person must 23/03/07 produce an up to date Statement of Purpose and Service User Guide. Not completed from last inspection with a timescale of 20/05/06 The registered person must ensure that all recruitment records are available at the home for examination if required. The registered person must ensure that there is a safe system of administration of medication to service users. 23/03/07 4 YA34 Schedule 2 17(3)(b) 13(2) 5 YA20 23/01/07 Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 26 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 5 6 Refer to Standard YA39 YA42 YA36 YA20 YA22 YA42 Good Practice Recommendations It is recommended that the service users have access to regular house meetings, which are recorded. It is recommended that the fire risk assessment is reviewed. It is recommended that the staff team receive at least six supervisions annually, which are recorded. It is recommended that staff receive ‘in house’ refresher training on medication procedures and policies. It is recommended that the manager keeps a record of any complaints at the home to enable them to be audited. It is recommended that the manager monthly audit all accidents every three months. Whitworth Road (130) DS0000061295.V319826.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Whitworth Road (130) DS0000061295.V319826.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. 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