Inspection on 17/09/07 for 160-162 West Wycombe Road

This inspection was carried out on 17th September 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

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

CARE HOME ADULTS 18-65 160/162 West Wycombe Road High Wycombe Buckinghamshire HP12 3AE Lead Inspector Joan Browne Unannounced Inspection 17th September 2007 09:30 160/162 West Wycombe Road DS0000069740.V351009.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 160/162 West Wycombe Road DS0000069740.V351009.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. 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 160/162 West Wycombe Road Address High Wycombe Buckinghamshire HP12 3AE 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) 01494 451453 ken.mcconaghie@hpcha.org.uk Hightown Praetorian & Churches Housing Association Mr Kenneth David McConaghie Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care Home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Mental Health, not falling within any other category (MD) The maximum numbers of service users to be accommodated is fifteen (15). N/A Date of last inspection Brief Description of the Service: 160 West Wycombe Road is a care home registered to provide care and accommodation to fifteen service users with a mental health diagnosis. The aim of the home is to provide longer-term accommodation whilst supporting service users to develop their skills to live independently. It is situated on a main bus route, halfway between the busy commercial centre of High Wycombe and the picturesque National Trust village of West Wycombe and its surrounding countryside. The home is managed by Hightown Praetorian and Churches Association Ltd, which is registered with charitable rules under the Housing Association’s Act 1985 and is a limited company under the Industrial and Provident Societies Act. The home consists of a two-storey building. There are thirteen bedrooms situated on the first floor, two bathrooms and a separate toilet. On the ground floor there are a further two bedrooms a bathroom, toilet, laundry room, two kitchens, a dining room, two lounges and a smoking area. Bedrooms do not have en suite facilities but are fitted with wash hand basins. The building is not accessible to wheelchair users and there is no passenger lift. The current weekly fees are £538.51. 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’ and was carried out on 17 September 2007. The inspector spent approximately six hours in the service and looked at how well the service was doing. The inspection took into account detailed information provided by the service’s manager Comment cards were sent to some service users, relatives and health and social care professionals. At the time of writing this report response to comment cards were received from three health and social care professionals. Their views and the views of service users and staff who were spoken to during the inspection are reflected in this report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Care plans were examined, which was followed by meeting with the individuals to see if the plan matched the assessed care needs. The medication system and accompanying records were examined along with staff rosters, staff recruitment files, training records and health and safety records. A tour of the premises was carried out and some time was spent meeting with service users and staff. From the evidence seen it was considered that the home was providing a good service to meet the diverse needs of individuals of various religion, race and culture. The inspector would like to thank everyone who assisted in this inspection in any way. What the service does well: Prospective people to use the service needs are assessed to ensure that they diverse needs can be met. Wherever possible staff ensure that people using the service are provided with assistance and the appropriate information to make decisions about their lives. Staff support people who use the service to make choices about their lifestyle and to develop life skills thus ensuring that the educational, cultural and recreational activities provided meet individuals’ diverse needs. 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 6 The home ensures that people using the service have access to an effective complaints procedure and there are policies and procedures in place to protect them from any potential abuse. The home ensures that staff that are appropriately recruited care for people using the service. The home has systems in place to ensure that people using the service health and safety are promoted. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 160/162 West Wycombe Road DS0000069740.V351009.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 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Prospective people to use the service are admitted on the basis of a full assessment undertaken by people competent to do so to ensure that their diverse needs are identified and planned for. EVIDENCE: The home has a detailed statement of purpose and service user’s guide in place. The documents were reviewed in April 2007. It was reflected in the home’s annual quality assurance assessment (AQAA) that each service user had been issued with an up to date copy of the documents and staff discuss the documents in detail with them during key working sessions and at the assessment stage. Case tracking confirmed good practice. Prospective service users were admitted only on the basis of a fully structured assessment. The home’s manager and the assistant manager carry out assessments to establish if the home is able to meet individuals’ needs. The prospective service user is expected to visit the home on at least one occasion and may stay overnight before confirming his or her intention to move in. There is an initial trial period of one month, which is followed by the placement being made permanent. 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 9 160/162 West Wycombe Road DS0000069740.V351009.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service have a care plan, which reflects their assessed needs and personal goals. However the plan could be improved further by ensuring that it clearly outlines any perceive restrictions on choice and freedom, which has been agreed with the person using the service. Wherever possible staff ensure that people using the service are provided with assistance and the appropriate information to make decisions about their lives. EVIDENCE: Two service users’ plans were examined. The plans contained personal details information sheets, pen pictures and lifestyle summary sheets outlining individuals’ preferred routines, specific likes and dislikes. Each plan included a care plan assessment tick list and from this supporting plans were put in place to meet identified needs. One plan was signed by the service user and the key worker, which confirmed the individual’s involvement in the drawing up of the care plan. The second plan was not signed by the service user and there was a written explanation why the individual did not sign the plan. 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 11 In one care plan information detailing how, when and why staff should be supporting the individual with personal hygiene was not evident. Restrictions on choice and freedom agreed with the service user were not clearly outlined in the plan of action. However, staff members spoken to were able to describe the agreement that was in place. It is recommended that detailed information should be recorded in individuals’ care plans to ensure that the plan outlines clearly any perceive restrictions on choice and freedom, which has been agreed with the service user. An identified need relating to food and drink should have been reviewed within a specific timescale. There was no evidence seen to confirm that the identified need had been reviewed and the information recorded in the plan was current. In the second care plan examined it was identified that the individual needed support with food and drink. There was no supporting plan in place to outline how staff should be supporting the individual. The inspector was told that work was in progress to transfer the existing care plans to the new organisation care plan format and for staff to undertake training in person centred care planning and the new organisation’s care documentation records. It is recommended that an audit system be put in place to ensure that supporting plans are in place for all identified assessed needs. Plans seen reflected that service users were being given the support required to assist them in making decisions. Service users spoken to confirmed that monthly meetings were held and they were encouraged to contribute to these meetings and provided with the opportunity to be involved in decisions, which affect them. A particular service user spoken to, was very excited and looking forward to moving on to independent living in the community. The individual said that staff were very ‘supportive’. At the time of the inspection no service users were using the services of an advocate. The home is able to access the service of an advocate if required. It was noted that several service users were managing their own finances with the appropriate risk management assessments in place. Financial records for the two service users whose care was case tracked were checked. The money held in the safe corresponded with the records. Information recorded on one particular sheet needed to be more comprehensible to ensure that there is a clear audit trail of transactions. As part of promoting individuals’ independence staff would ensure that risk assessments plans were in place to assist them in maintaining an independent lifestyle. Due to health and safety risks and to protect service users the main kitchen is closed at night. Arrangements were in place to ensure that individuals are able to access snacks and drinks if required. 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 12 Care managers who responded to the Commission’s comment cards felt that there were some areas relating to choice and decision- making in which the service should consider to further improve the service delivery. The following comments were noted: ‘To be a little more flexible about resident choice and managing risk in order for people to move on and take more control of their lives.’ ‘I think that the principles of service user empowerment need to be considered more in the decisions made by the care service and the wishes of service users taken into account. Giving residents the opportunity to make their own decisions and mistakes which in this safe environment can provide valuable learning experiences which help them to manage their lives when they have left the service.’ 160/162 West Wycombe Road DS0000069740.V351009.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Staff support people who use the service to make choices about their lifestyle and to develop their life skills, which should ensure that the educational, cultural and recreational activities provided meet individuals’ diverse needs. EVIDENCE: Discussions were held with several service users who were happy to share their experiences on what it was like living in the home. One particular service user was being supported by staff in developing employment skills and was working with the local national trust. Other service users were pursuing vocational training in information technology, literacy and numeracy. Care plans seen reflected that there was a weekly programme of planned individualised activities to meet service users’ cultural and diverse needs. The activity programme for individuals consisted of badminton, football, bowling, attending day centres, regular visit to the gym and to local football matches, shopping independently or with the support of staff on a weekly basis. Service 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 14 users said that they regularly attended shows at the local theatre and were looking forward to attending a matinee performance within the next couple of days. Care plans examined for the two individuals whose care was tracked reflected the level of support that they required to support them to maintain links with family members. Staff spoken to said that service users’ family and friends were made to feel welcome. Visitors were able to see individuals in their bedrooms or in the communal areas. Service users who wish to were able to develop and maintain intimate relationships with individuals of their choice. Service users confirmed that staff enter their bedrooms with their permission and in their presence. All service users were issued with a key for their bedroom and the front door. Staff ensure that individuals’ letters are distributed daily. Plans seen reflected individuals’ preferred term of address. Service users spoken to said that they were encouraged to take an active part in housekeeping tasks. At the daily morning meetings each person is allocated a specific housekeeping task that they are expected to complete during the course of the day. There is a smoking room provided and the rules on smoking, alcohol and drugs were outlined within the service agreement and contract. Service users spoken to confirmed that they were provided with three meals daily and unlimited amount of tea, coffee and snacks. All meals were expected to be eaten in the dining room. Individuals are encouraged to prepare their own breakfast and lunch. Staff members assisted by service users prepare supper. There is a menu-planning meeting that is held monthly to discuss the menu for the forthcoming weeks. Provision is in place to ensure that service users have an alternative if they do not like what is on offer. Special diets were being catered for such as vegetarian. 160/162 West Wycombe Road DS0000069740.V351009.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 People who use the service experience ‘good’ quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has systems in place to ensure that the health and personal care that people receive is based on their individual needs. Some areas of the medication process could be improved by ensuring that handwritten entries on the medication sheets be checked by a second person to minimise the potential risk of errors. EVIDENCE: Support plans examined reflected the level of assistance and support required by individuals to promote their personal care needs. There were no service users requiring assistance with washing and dressing. Individuals’ appearance on the day of the inspection was clean and tidy with attention to detail. Service users spoken to said that they choose the times they wish to rise and retire. Staff confirmed that service users have access to the general practitioner and they were able to access specialist support and advice if required. Service users have regular reviews with the community mental health team. Some 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 16 individuals spoken to said that they attend medical appointments independently. Care managers who responded to the Commission’s comment cards said that the home ‘always’ or ‘usually’ monitor individuals’ health care needs properly. The following comments were noted: ‘Very good monitoring of health care needs.’ ‘Clients receive appropriate care.’ Wherever possible service users were encouraged to self-medicate and this was supported by the home’s medication policy with the appropriate risk assessment in place. A large number of service users were at the stage where they were dispensing and administering their own medication in the presence of a staff member. The medication administration record sheets were examined and some sheets had scribbled over entries. This is not a good practice and should cease. Entries recorded in error should have a written explanation recorded for example, recorded in error. It was noted that staff were not using the appropriate code when medication was offered to individuals and was refused. Staff were recording X instead of R for refuse. It was noted that handwritten entries on the medication administration record (MAR) sheets were not countersigned by a second person. It is recommended that handwritten entries on the MAR sheets should be checked by a second person to make sure that the risk of transcription errors is minimised. 160/162 West Wycombe Road DS0000069740.V351009.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The home has policies and procedures in place to ensure that people who use the service are able to express their concerns and have access to a robust complaints procedure and are protected from abuse. EVIDENCE: The home has a complaints procedure. Service users spoken to during the inspection said that they were aware of the procedure and knew who to refer to should they wish to make a complaint. Information recorded in the home’s annual quality assurance assessment (AQAA) indicated that the home had received one complaint, which was investigated and resolved within twentyeight days. It is pleasing to report that the Commission had not received information concerning any complaints made against the service since the last inspection. Respondents to the Commission’s comment cards said that the service ‘usually’ responded appropriately to any concerns raised. The inspector was shown a complimentary note that the home had received from a service manager. The home has guidelines and procedures in place to protect service users from any potential risk of harm or abuse. It is also guided by the Buckinghamshire interagency safeguarding of vulnerable adults policy and procedure. Staff spoken to were aware of their responsibilities in working with vulnerable adults and had undertaken training in the safeguarding of vulnerable adults. The home has not reported any incidents in relation to the safeguarding of vulnerable adults. It is also pleasing to report that the Commission had not 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 18 received any information concerning any suspicion or evidence of abuse or neglect made to the service. 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 19 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 People who use services experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is clean and hygienic, however some maintenance work to the premises is needed to ensure that people using the service live in a comfortable and safe environment. EVIDENCE: The home is a large house that consists of fifteen bedrooms. Each room is fitted with a wash hand basin, bed, bedside cupboard, chair, wardrobe and dressing table. There are three bathrooms with shower facilities five toilets, two communal lounges, a dining room, two kitchens and a laundry room. There is also a large patio area and attractive gardens. The home does not have a passenger lift and is not accessible to wheelchair users. This information is reflected in the service user’s guide but not in the home’s statement of purpose. During a tour of the building the following maintenance work to the premises was identified as needing attention: • The carpets in the dining room and lounge area were heavily soiled and required replacing • The net curtains in the dining room were torn and required replacing 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 20 • • • • • • The work surface in the main kitchen was chipped and required replacing Several wall tiles in the main kitchen were chipped and required replacing The cover on the foot pedal bin in the main kitchen was rusty in some areas and must be replaced to prevent the spread of bacteria The washer on tap in the main kitchen required replacing The paintwork on the walls in the training kitchen was flaking and required repainting The freezer in the main kitchen required defrosting The home was free from offensive odours on the day of the inspection. The home employs two housekeeping staff that are responsible for cleaning the communal areas and bathrooms and toilets. Service users with support from their key workers are responsible for cleaning and maintaining their bedrooms. The laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared cooked or eaten and do not intrude on service users. As part of developing daily-living skills service users are responsible for their own personal laundry. 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 21 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that staff employed have been appropriately recruited. A significant number of staff had achieved the national vocational qualification (NVQ) in level 2 and above. Further work is needed to ensure that mandatory training for all staff is updated in line with current guidelines and to ensure that people using the service are supported by staff that are trained and skilled to meet their diverse needs. EVIDENCE: There were sufficient numbers of staff to meet the needs of the service users on the day of the inspection. Service users spoken to said that staff were accessible and approachable. Staff were observed throughout the inspection interacting with service users in a professional and sensitive manner. It was noted that the staff team had been through a period of transition and change. Information reflected in the home’s AQAA indicated that ‘throughout the transition staff had been supported by effective management systems. Staff retention had remained significantly high. Management had re-defined roles and responsibilities, highlighting accountability and the importance of clear documentary evidence in working with and for service users. NVQ had 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 22 successfully been prioritised’. It was noted that six staff members had achieved the national vocational qualification (NVQ) in level 2 or above. A further three staff were working towards achieving NVQ level 2. Staff spoken to were positive about the changes that had been introduced and were looking forward to their successful implementation. Respondents to the Commission’s comment cards said that staff ‘usually’ or ‘sometimes had the right skills and experience to support individuals. Four files for staff members who were recently appointed were examined. All files contained all the required information and complied with the current guidelines and regulations. The home’s training matrix reflected that some mandatory training for staff members needed to be updated. It was noted that training in moving and handling, fire awareness, first aid, infection control and break away was outstanding. The manager said that he was aware that some mandatory training required updating and was liaising with the organisation’s training coordinator to ensure that training was provided. The organisation has an electronic facility called E-Learning where staff could sign on to update some mandatory training on line. However, not all staff had acquired information technology (IT) skills and therefore needed to be trained to use the facility. A requirement is made in this report to ensure that mandatory training for all staff is updated. 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 23 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People who use the service benefit from a home that is based on openness and respect. Health and safety records seen were in order and should indicate that people using the service health and safety are protected EVIDENCE: The registered manager has twenty-five years of experience supporting people within the social care sector. Sixteen of these years have been in management positions. He holds the certificate in social services and the NVQ 4 registered manager’s awards and the assessor’s accreditation. He has experience of working with older people in care homes, sheltered accommodation and within the community providing support for people who have varying levels of mental health disabilities. 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 24 He is actively involved in ensuring that the aims and objectives of the home are achieved. Implementing policies and procedures and ensuring that the home’s budget is properly managed. It was noted that relevant certificates and licences were prominently displayed in the front entrance of the home. Staff and service users spoken to said that the manager was approachable, listens and acts on suggestions. Minutes of meetings were seen, which confirmed that regular staff meetings take place. It was noted that equality and diversity issues were often discussed at staff’s meetings to raise staff’s awareness and to ensure that individuals are not discriminated against because of their sex, age, disability, race culture or religion. A senior manager from the organisation visits the home unannounced monthly. Staff and service users are spoken to and a report of the visit is completed. The manager said that he was focussing on bringing the service fully in line with the new organisation’s expectation. His aim in achieving this was by gradual implementation of all policies, procedures and guidelines. Examination of a sample of health and safety records indicated that they were up to date and in good order. Some concerns were raised during the inspection on the validity of the fire risk assessment for the building. The manager has since confirmed that an up to date fire risk assessment was undertaken and a copy of the assessment was now available in the home. Routine servicing and maintenance of equipment is undertaken at appropriate intervals to maintain the home as a safe and risk free environment for people using the service. 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 3 X 3 X 2 X X 3 X 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 26 N/A 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 YA24 Regulation 23(2)(b) Requirement Maintenance work outlined in the body of this report as needing attention must be carried out to ensure that people using the service live in premises that are kept in a good state of repair. Mandatory training for all staff must be updated to ensure that people using the service are supported by staff that are appropriately trained to the work they are to perform. Timescale for action 31/10/07 2 YA35 18(1)(c) 31/10/07 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 Refer to Standard YA6 Good Practice Recommendations Detailed information should be recorded in individuals’ care plans to ensure that the plan outlines clearly any perceive restrictions on choice and freedom, which has been agreed with the person using the service. An audit system should be put in place to ensure that supporting plans for people using the service are in place for all identified assessed needs. DS0000069740.V351009.R01.S.doc Version 5.2 Page 27 2 YA6 160/162 West Wycombe Road 3 4 YA7 YA20 5 YA20 6 YA20 Financial sheets for people using the service should be more comprehensible to ensure that there is a clear audit trail of transactions. Entries recorded in error on the medication administration record (MAR) sheets should have a written explanation to comply with the Royal British Pharmaceutical Society best practice guidelines. When medication is offered to people using the service and it is refused staff should use the appropriate code to comply with the British Pharmaceutical Society best practice guidelines. Handwritten entries on the MAR sheets should be checked by a second person to ensure that the risk of transcription errors is minimised. 160/162 West Wycombe Road DS0000069740.V351009.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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