Inspection on 25/05/07 for 18 Spindlebury

This inspection was carried out on 25th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

18 Spindlebury 13/12/05

18 Spindlebury 04/05/05

18 Spindlebury 25/11/04

18 Spindlebury 08/07/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

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

CARE HOME ADULTS 18-65 18 Spindlebury 18 Spindlebury Padbrook Cullompton Devon EX15 1SY Lead Inspector Louise Delacroix Unannounced Inspection 25th May 2007 10:30 18 Spindlebury DS0000036966.V334987.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 18 Spindlebury DS0000036966.V334987.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. 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 18 Spindlebury Address 18 Spindlebury Padbrook Cullompton Devon EX15 1SY 01884 33530 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) Brain Injury Rehabilitation Trust Mrs Penny Jean Blackmore Care Home 2 Category(ies) of Physical disability (2) registration, with number of places 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 13th December 2005 Brief Description of the Service: Spindlebury provides rehabilitation care and support for two people with an acquired brain injury. The home is part of the Brain Injury Trust and works closely with the professionals within the Trust. The professionals based at The Woodmill Brain Injury Unit carry out all rehabilitation and therapeutic assessments/programmes for the service users living at the home in conjunction with the carers and House Leader working at Spindlebury. The home is a bungalow situated in a modern housing estate in Cullompton. Minor adaptations have been made to the house to meet the current service users physical needs. The home is within walking distance to the local amenities, including public transport. The emphasis in the home is to support people become more independent, in and out of the home, to seek employment and training opportunities, and maintain regular contact with relatives and friends. The weekly cost is £1262.50. Additional charges are made for toiletries, sweets, clothes and shoes. 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted approximately three hours at the home, with a further hour spent at The Woodmill (another BIRT home) where staff recruitment and training files are kept and the registered manager is based. Both of the people living at the home were present and played a key role in contributing to the inspection. Time was also spent talking with a member of staff. Medication, staff recruitment and training files, personal allowance files for people living at the home, and plans of care were also looked at. The Commission for Social Care Inspection (CSCI) asked for the home to send out a range of surveys published by the Commission to gain feedback from people in contact with the service. One visitor and one health professional responded. Surveys were also sent to the small staff team and the people living at the home. All responses have been included in the report as has details from the home’s pre-inspection report which gives details about the service and is completed by the registered manager. What the service does well: Comprehensive assessments and introductory visits to the home take place before people move in. Care records are maintained to a high standard with a strong focus on each person’s individuality and personal goals. People living at the home are encouraged to make choices in their lives and are supported to do so by skilled staff. They are also involved in day-to-day decisions i.e. choosing meals and supported to achieve their long-term goals of independence. They are protected by good medication practice and risk assessments that recognise their emotions and choices. There are strong links to the community with a visitor stating that ‘staff are very committed to maximum exposure to as normal as life as possible’. People living at the home are involved in work placements, college groups and work skills groups that build on their strengths and interests. People living at the home feel listened to and know who to go to if they have a problem. Staff are well informed about safe guarding the people using the service. Training is promoted, and includes specialist training linked to the needs of people using the service. The atmosphere throughout the inspection was relaxed and friendly with both people living at the home appearing at ease and comfortable in the homely environment. The following quote from one person living at the home sums up a discussion with them about the service ‘they are fabulous, they give us a lot of support and belief to try something new’. 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 6 The home is maintained to a high standard and is well located and meets the needs of the people living there. As always the home was clean, odour free and well maintained with up to date safety checks. The home is well managed and staff feel supported. There are both informal and formal ways of monitoring the service to ensure that residents benefit from a caring and professional environment. 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. 18 Spindlebury DS0000036966.V334987.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 18 Spindlebury DS0000036966.V334987.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): Standards 2 and 4 were looked at. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home ensures through a thorough and comprehensive assessment process that they can meet the needs of people moving to the home. Prospective service users are actively involved in moving to the home, which enables them to make decisions about whether the service will suit them. EVIDENCE: Full assessments are carried out prior to admission to the home. The assessments are detailed, and cover all issues in a holistic manner, as well as recognising the individuality of the person concerned. Care plans are then generated from these assessments. Rehabilitation and therapeutic needs are assessed by a multi-disciplinary team based at The Woodmill (a nearby BIRT home) and are incorporated into the plan of care. Records show that relatives/representatives and service users are involved in the assessment process. A person who had recently moved to the home spoke about how being able to visit before moving in had enabled them to make a decision as to whether it was the right place for them. They had also been able to visit another BIRT home, and found the contrast between the two helpful and enabled them to 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 9 feel confident about their decision. They said they had been asked if they wanted to move to the home and had been able to meet staff. There was a strong sense that they felt very involved in the move to the home and were well informed about what the service could provide for them giving them a clear set of expectations, which was reflected in their care records. Another person said it was difficult to remember how they had made the decision but remembered being able to discuss the home with their family. 18 Spindlebury DS0000036966.V334987.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): Standards 6,7 and 9 were looked at. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care needs are well met in an individual manner by caring and informed staff. The ethos of the home promotes the rights of people living there to make choices in their lives, and to be involved in setting the goals they wish to achieve. EVIDENCE: People living at the home spoke about their own personal goals, which were clearly represented in their plans of care (these outline the type of support people need). The plans of care are well worded and sensitively portray how support should be provided that recognises the person’s strengths and areas for development. The plans of care acknowledge that the success of support relies on the person living at the home being in agreement with the approach. Plans of care reflect changes in people’s lives. A staff member explained how a change in approach to promote communication had happened to reflect changes in the person’s life. This change was reflected in the plan of care. Staff 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 11 had a clear understanding of the needs of the people living at the home, which was reflected in their positive relationships with service users. The people living at the home had signed their own plans, and at the time of the inspection one person was sitting with the house leader to discuss the content of their care plan. Where there are restrictions or issues for concern, there are clear individualised procedures to help ensure staff provide a consistent approach. Reviews take place on a regular basis, and changes are made where needed. A visitor confirmed this. Care records show the views of people living at the home. People living at the home explained, as did a staff member, that they are provided with opportunities to make decisions about their lives either through reviews or informally on a day-to-day basis i.e. choosing meals or the decoration of the home. Both residents have chosen to improve their general fitness and there was evidence of them making decisions about how often they went to the gym. One person said ‘We have a choice’. They both spoke about their goals and felt well supported by staff to achieve these. A health professional that has long standing links to the home said that the service always supported individuals to live the life they chose. Plans of care and discussion with staff and people living at the home clearly show that risks and hazards are openly discussed and recorded. Daily records show the staff team’s awareness to monitor progress and help achieve identified goals. The home benefits from a multi-disciplinary team approach, which helps ensure a creative and skilled approach towards risk taking. One person spoke about their past lifestyle and the changes they wanted to make, which they felt the staff team were helping them to achieve. A staff member explained how a staggered approach with in built reviews was being used in order to overcome a recognised risk in the person’s life. 18 Spindlebury DS0000036966.V334987.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): Standards 11,12,13,15,16 and 17 were looked at. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at the home are supported to reach their individual aspirations and fulfil their potential by staff who respect them. Meals at the home suit the individual tastes and needs of the people living there. EVIDENCE: One person living at the home was very clear that they were learning social and life skills to achieve their goal to move out. They were clear about how their personal development was progressing, which was echoed by staff and reflected in their plan of care. People living at the home spoke about their access to a work skills group at The Woodmill. Both people have recently started therapeutic work placements that have been tailored towards their own interests and skills. Both people showed pride in their work and interests i.e. pottery and flower arranging. Daily records show how staff ensure that these placements promote each 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 13 individual’s sense of well-being and how these placements build on current strengths and develop others. Plans of care show the work that has gone into ensuring that the work placements are supportive and rewarding. From talking with people living at the home there is a sense of their awareness of their place in the local community and that they are able to access local amenities including shops and local gym, which was shown by daily records. A visitor commented that the home was ‘very committed to as full as life as possible in the community’. Although also in their survey and a staff member’s survey it was suggested there should be greater access to transport. Currently, a minibus is shared with The Woodmill and a third BIRT home. During the inspection, it was clear from discussion, observation and care records that both people are supported to stay in touch with people that are important to them. The home’s manager and a member of staff both displayed sensitivity that in some situations this was difficult and that support needed to be offered tactfully. A visitor said that one of the people living at the home was usually helped to keep in touch. Staff always showed an awareness of the impact of having a brain injury on both the people living at the home and the people close to them. People are supported to remember birthdays and significant events in their lives to help maintain contact with people important to them. Care records show recognition of the importance maintaining people’s self worth and image, including their sexuality. Staff and people living at the home spoke about the importance of friendships and supporting people living at the home to be able to develop relationships safely. People living at the home looked relaxed in their surroundings. For example, choosing to spend time alone when they wished to. There was a clear sense of each bedroom belonging to each individual, and people living at the home answer the phone showing a sense of ownership of the home. Both people spoke about routines within the home, they both felt they could do what they wanted with one person recognising that a routine helped them. People living at the home spoke about being actively involved in planning meals through joint discussion, normally on a daily basis, and by go shopping for the ingredients. Records of meals have been provided by the home, and these reflected the choices discussed by people living at the home. Staff support people with preparation which was seen on the day of the inspection. This support is provided in a friendly and enabling manner. 18 Spindlebury DS0000036966.V334987.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): Standards 18,19 and 20 were looked at. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service provides excellent support and care, which reflects the individual physical and emotional needs of the people living at the home. Peoples health needs are protected by good medication practice, and good access to health care services. EVIDENCE: People of the same gender as the service users staff the home. Records show that mealtimes are flexible, as are times to go to bed and get up. As there is one member of staff on duty there is the potential for service users’ individual routines to impact on one another. However, it would appear from discussion that this has not been problematic for the people currently living at the home, with records showing that one to one time has been provided for each individual. A visitor to the home said that the service always met the individual needs of the people living there. A tour of the building showed that the home has appropriate equipment to enable residents, and staff said specialist advice could be easily accessed if people’s needs change, which was shown in the plans of care. 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 15 The health care needs of the service users are highlighted in individual plans of and are monitored. A staff member explained how an appointment with a GP of the same gender as a service user had been made when requested by the person. Another person said they were also supported to access health services, while staff showed a good understanding of the health needs of the people living at the home. There was evidence in care records of good links with other health care professionals, and ensuring that service users receive the health care they need. Records showed an appreciation of the importance of people’s sense of self worth and body image. Clear guidance was given for recognised risks/reactions regarding support with personal care, and reviews take place to ensure the guidance is working both for staff and the person living at the home. A staff member said they felt well supported by the multi-disciplinary team to help people meet their individual personal care needs. A health professional who has long standing links to the home said that people living in the home always have their health care needs met by the service and that medication is always managed correctly. Medication records were checked and appropriately completed with medication securely stored. Staff said that they received appropriate medication training, training records were seen, and had their practice observed by a senior staff member to ensure good practice. They also said that new members of staff had their work observed until their competency was confirmed. They felt well supported with medication issues and were clear who they would go to if there was a medication issue and their own professional responsibilities. 18 Spindlebury DS0000036966.V334987.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): Standards 22 and 23 were looked at. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are safeguarded by well-informed staff and well kept records. EVIDENCE: The home has a comprehensive complaints procedure, which has also been produced in a format suitable to the needs of the people living there. There have been no complaints at the home since it has opened. Neither person living at the home wished to raise any concerns during the inspection. Both were clear about who they would go if they had a complaint. One person said ‘There’s always someone there if there’s a problem’. A visitor to the home said they knew how to make a complaint and said that if they had raised concerns they were always responded to appropriately by the service, which was confirmed by a health professional. No complaints have been received by CSCI about the service. Vulnerable adult training is addressed in the first three levels of in-house training, which is open to all care staff. The staff member on duty confirmed that they had received recent training in this area, was aware of their responsibility to challenge poor practice and knew who to go to both within and outside of the organisation. Staff files show that appropriate safeguarding training has taken place for new members of staff, including the provision of the home’s policies on protection of vulnerable adults and whistle-blowing, which details staff responsibility to report poor or abusive practice. Staff had 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 17 signed these for. A spot check evidenced that financial records were well kept and correct, with receipts kept so that transactions could be audited. 18 Spindlebury DS0000036966.V334987.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): Standards 24 and 30 were looked at. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The maintenance and décor of the home is maintained to a high standard, and provides a clean and homely atmosphere for people living there. EVIDENCE: The home blends in with the neighbouring bungalows. Each person has a single room, one of which is en-suite, and they have use of all other parts of the home, apart from the office. There is a communal domestic sized bathroom. The lounge and dining room can be used as one room or used separately to create greater privacy for people with visitors. The home is decorated in an attractive style, which people living there helped influence and is well maintained. Both people living at the home expressed happiness with the environment. One person spoke about how their bedroom had been decorated to their taste, which was important to them as the colour had a positive effect on their mood. Furnishings are of a good quality with fixtures and fittings regularly updated and to a high standard. 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 19 A second more direct path in the front garden has been laid and the patio has been extended to make it more accessible. Minor adaptations have been made to accommodate the physical needs of the people living at the home i.e. grab rails. There is a planned maintenance and renewal programme for the home. The home is clean and odour free. Both people living at the home said this was always the case, with one person saying ‘we all do our bit to help’ and describing the domestic tasks they undertook around the home to promote their independence. 18 Spindlebury DS0000036966.V334987.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): Standards 32,33,34 and 35 were looked at. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a small committed staff team, who are well recruited and whose training opportunities and skills benefit the people living at the home. EVIDENCE: Staff benefit from a good range of training provided by the Brain Injury Trust and an audit is kept at The Woodmill of staff training needs. Training covers mandatory courses, as well as more specific training relating to the needs of the client group, which is also part of the induction. One member of staff is currently working through their induction, which includes a comprehensive workbook to promote good practice. One person living at the home said the staff group ‘are so good’: the other person said they are ‘excellent’. A heath professional and a visitor said the staff group always had the right skills and experience to look after people properly. Discussion with a staff member showed their own personal development, which they also demonstrated in the way daily notes are written to focus on the goals chosen by the people living at the home. A staff member 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 21 said that their mandatory training was up to date, which was confirmed by staff training files. In response to a CSCI survey, two staff members said that the home provided funding and time for training and that their work is observed. Staff were observed following techniques and guidelines stated in plans of care, and subtly supporting people living at the home to plan and structure their time. Staff in response to a survey said they were never asked to care for people outside of their expertise. Staff take a pride in the their work as seen during the inspection, and in their response to the CSCI survey. The staffing group is currently stable; although illness or annual leave has meant staff from other BIRT homes have stepped in to provide cover when necessary or agency staff are used. A staff member said that where possible continuity is maintained by using named agency staff who know the client group. Two staff recruitment files were looked which showed that appropriate information had been gathered to help ensure that staff members are suitable for the job they undertake. This includes police checks, two written references, suitable identification and explanations for gaps in employment. 18 Spindlebury DS0000036966.V334987.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): Standards 37,39 and 42 were looked at. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This is a well-managed service that has processes to ensure that people living in the home are consulted about the service. Health and safety is managed well at the home, and one minor improvement will further protect the people living there. EVIDENCE: The house leader manages the home on a daily basis supported by the registered manager, who is based at The Woodmill. In discussion, staff were clear about the lines of responsibility, and confirmed that the registered manager has regular contact with the home. Discussion with the registered manager about the people living at the home and issues related to the service demonstrated an up to date knowledge. The registered manager continues to up date her professional training. In response to the CSCI survey, staff said 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 23 they felt well supported and that they met regularly with the registered manager. Staff members confirmed that there are regular visits by the management team and the multi-disciplinary team (many of which are unannounced) to the home, which act as a monitoring role. People living at the home are given the opportunity to meet with management on an informal basis. Their relationship with management was observed to be relaxed and friendly. Staff explained that house issues are discussed informally with people living at the home. The house leader then discusses the outcome or issues with the clinical team based at The Woodmill. The house leader then feeds back the responses/action from the meeting. People living at the home have said on previous inspections that they prefer this informal approach. Review minutes also evidence that service users can put forward their viewpoint or ask for a representative to do this on their behalf. Qualified staff from the multi-disciplinary team review moving and handling techniques used with people living at the home and staff, and changes are recorded in the plans of care. Staff confirmed quality assurance visits occur at appropriate intervals. The home’s pre-inspection questionnaire states that health and safety checks happen at appropriate intervals. Staff records show that they receive regular fire training, which was confirmed by a member of staff. A generic risk assessment is in place for radiators in the home but this does not detail the individual level of risk for each person living at the home and does not identify an increased level of support for one person. 18 Spindlebury DS0000036966.V334987.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 x 2 4 3 x 4 3 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 4 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 4 12 4 13 3 14 x 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 3 x 4 x x 2 x 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 13 (4)(c) Requirement A risk assessment for individual uncovered radiators in the home must take place, and action taken to guard the radiator if the risk is medium or high. Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 18 Spindlebury DS0000036966.V334987.R01.S.doc Version 5.2 Page 27 - 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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