Inspection on 23/07/07 for 20 Boadicea Close.

This inspection was carried out on 23rd July 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 20 Boadicea Close Cippenham Slough Berkshire SL1 5UJ Lead Inspector Kerry Kingston Unannounced Inspection 23rd July 2007 10:15 20 Boadicea Close DS0000069484.V338961.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 20 Boadicea Close DS0000069484.V338961.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. 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 20 Boadicea Close Address Cippenham Slough Berkshire SL1 5UJ 020 343 8897 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) www.Adepta.org.uk Adepta Mrs Mary Margaret Hill Care Home 5 Category(ies) of Learning disability (0) registration, with number of places 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New Service Brief Description of the Service: 20 Boadicea Close is a purpose built home for five female residents with a learning disability, some have associated physical disabilities. The home is located on a residential housing estate in Cippenham, Slough, it provides accommodation and twenty-four hour care. The home is operated by Adepta and owned by Windsor and Maidenhead Housing Association. It is a single storey building, which provides ground floor accommodation in two dwellings, linked by a central foyer. Two people live in one side and three in the other. The dwellings can operate independently or as one home. A range of specialist adaptations have been made to the home in order to meet the needs of residents with physical disabilities. The home is near to local shops and facilities and a few miles from the Town Centre, it shares transport with a nearby home and residents are able to use public transport or taxis to access the community. This was the first inspection of the service under the new providers, Adepta, who took over responsibility for the home on the 19th of March 2007. The fees are £98,725 per annum, with residents contributing £65 per week to the costs. 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report for the key inspection, which included a routine unannounced site visit. This took place between the hours of 10.15am and 6.00pm on the 23rd of July 2007. The information was collected from an Annual Quality Assurance Assessment, a document sent to the home from the Commission for Social Care Inspection and completed by the manager, surveys which were sent to people who use the service, other professionals and families of residents. One survey from a resident, two surveys, which were completed by families and one survey from another professional were received in response. Discussions with two staff members, the registered manager and one person who use the service took place. Only one resident is able to verbally communicate so some time was spent observing staff and the people who live in the home. A tour of the home and reviewing residents and other records was also used to collect information on the day of the visit. What the service does well: The home makes sure that peoples’ care plans say what they need and how they like to be helped so that whichever staff are on duty they know how to look after them. The home makes sure that people are supported to get any help they may need to keep them healthy and happy. The home makes sure that people are safe and that any problems they or their families/friends have are dealt with properly, even though there is not a way of complaining clearly written down at the moment. The home is nicely decorated, kept nice and clean and there is plenty of room for people to move about. Special equipment is provided so that people can be moved safely and kept as comfortable as possible, if they have difficulties moving about. The staff do their best to make sure that they understand what people want and are saying to them, even if they cannot talk in the usual way. The home is well managed and staff have worked hard to make sure that whoever runs the home makes no difference to the good care that residents receive. 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 6 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. 20 Boadicea Close DS0000069484.V338961.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 20 Boadicea Close DS0000069484.V338961.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): People who use the service experience adequate quality outcomes in this area. The home has not completed all the necessary documents to ensure that the people who live in the service can be clear about what they can expect from the home and what is expected from them. The home makes sure that peoples’ assessments are up-to-date and that they can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an up-to-date statement of purpose, which has been reviewed since the service was transferred to the new providers on the 19th March 2007. It is not yet in a user-friendly format and there is not a supporting service user guide. Contracts have been completed but not individualised, a ‘licence agreement’ is to be provided in addition to the contract for each individual, this work has not been completed yet. There is a procedure for admissions that would be followed in event of a new service user but there are currently no vacancies and none are expected, in the foreseeable future. 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 9 New core assessments for all the residents were completed by their care manager in May 2007 but the home does not have copies of these yet. The care manager confirmed to the manager of the home that she would receive copies of the core assessments by the end of the week. The people who use the service have been resident in the home for many years, three since 2000 and two since 2003. A resident confirmed that she had made many visits to the home whilst it was being built and had chosen to live there. 20 Boadicea Close DS0000069484.V338961.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): People who use this service experience good quality outcomes in this area. The home has detailed individual plans to make sure that they meet peoples’ diverse needs. Staff help people to make as many choices as they can about their everyday life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five individual plans were looked at and they included all the necessary information to enable staff to meet their needs. They included culture/religious/diversity needs such as one person being having a specific faith but being non-practising, it was clear that much thought had been given to whether it was appropriate to find an advocate of the same faith or to change her lifestyle when she had not been involved in her faith since she was a child. Individual plans also include ‘How to keep me healthy and safe’, ‘How I communicate with you’, Likes/dislikes/food and drink, morning routine including detail of how to offer choice to the person, afternoon and evening routines including how people display choice, what I like to wear, including jewellery and going out clothes. 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 11 The core assessment of needs completed in 2005 includes identified risks, the core assessment was up-dated in May 2007. The manager advised that there are plans to do monthly reviews of the care plans to ensure that they are always up-to-date. One care plan noted the type of entertainment preferred by the individual to enhance her belonging and understanding of her culture and how she expresses her religious views and feelings. Instructions about cross gender personal care also took account of peoples’ preferences and cultures. Key workers are chosen carefully, as far as possible with reference to individuals’ culture and background so that they can help individuals with any of their equality and diversity issues. The needs of the people in the home are very diverse and these are reflected in individual care plans to ensure that staff are able to identify and meet them. One person whose needs are dissimilar to the other residents described where she used to live and why she now lives at Boadicea Close, she said ‘I really like living here’ and ‘Staff let me choose things for myself and know what I need and when I need help’. There are extensive and detailed risk assessments for all residents, these are up-to-date, reviewed by staff at identified intervals and looked at during annual reviews to ensure they are still valid. Risk assessments included community activities, household activities and safety in the home. 20 Boadicea Close DS0000069484.V338961.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): People who use this service experience adequate quality outcomes in this area. People who live in the home are not supported to participate in enough regular activities and outings to add interest to their daily lives. They are helped to make decisions about their routines and are supported to keep in contact with their family and friends. The residents are provided with good quality food of their own choosing and according to their need. Overall, people experience a pleasant lifestyle that could be enhanced by additional activities and outings being provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individuals do not have a planned activities programme, some residents have half day sessions at day services, a maximum of three per week. There are no activities planned in advance for those people who are not attending the external day services. Recording does not, clearly, show what activities people participate in. 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 13 The manager said that outings and activities take place, regularly but no records or evidence of them was available. One resident said that she gets taken shopping and wants to pack things during the day, she has no activities plan or programme. She also said that she often likes to entertain herself in her bedroom or on her swing in the garden. The manager advised that she changes her mind and will not participate in activities, her opportunities to participate were not recorded. Daily notes recorded that one person had one outing in a week, another had two half days at the day centre and one swimming session and another had three half days at the day centre and one hospital appointment. The people who use the service have not been on holiday for over two years as there is no provision for additional payments for staff that accompany them. The home has a leased, specially adapted vehicle, which is shared between them and a nearby home. It has not been agreed how much individuals will contribute to the provision of the vehicle, but this needs to be included in the licence agreements or contracts, the Statement of Purpose says that some transport costs are covered in the fees, this should be clarified. One person showed me her bus pass that enables her and her carer to travel free on local buses. Families are encouraged to keep in contact with their family members and four of the five people maintain links with families and friends. One person does not have any family involvement although the home has, unsuccessfully tried to keep the contact. Surveys were received from two families, these stated that the contact with the home was positive. A parent was informed of a safeguarding situation after its’ resolution. Key workers are in regular contact with families who regularly visit the home. Residents are also supported to visit family homes, as appropriate. The routines of the house follow the needs of the residents, are as flexible as possible and take into account resident choices. Resident meetings are not recorded and peoples’ views are not recorded, currently. People make decisions and choices by displaying behaviour and communicating by their individual methods, which are noted on care plans, these are not always recorded on the daily notes. Menus seen were varied and good quality food is offered. At lunchtime, staff were observed helping some people with meals and giving support according to the detail included in the meal time routines on the care plan. One person was seen being offered alternatives, as she appeared not to be enjoying the lunch, even though it was something she usually liked. Menus are generally organised by staff based on observation of what people eat well and do and don’t like. One person said that she eats whatever she 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 14 wants and she can choose where she wants to eat. She also described the foods that she didn’t eat because of her religion, she confirmed that staff knew about her food requirements. One staff member clearly described how they gave people choices and tried to abide by their decisions wherever possible. Staff were observed interacting positively with those people with little verbal communication, interpreting their behaviours and responding to their needs. Residents were comfortable and confident to make their choices known. Staff members quickly identified what was being communicated and responded immediately to the residents requests. One person was seen entering the building with her own key and she advised me that she also had a key to her bedroom door. 20 Boadicea Close DS0000069484.V338961.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): People who use the service experience good outcomes in this area. The home meets peoples’ personal care needs in the way that they prefer and ensures that they are helped to stay physically and emotionally healthy. The home makes sure that medication is stored and administered safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for the five residents include ‘To keep me healthy and safe’ and likes and dislikes. Preferences note how people like to be handled and whether they prefer same gender or cross gender personal care. One resident has only same gender care although others receive cross gender, with their or their parent’s agreement. One staff member explained how he ensures his and the resident’s safety by sensible and sensitive working practices, but this needs to be ‘backed up’ by a cross gender policy, this was discussed with the manager. Male staff do not do ‘waking night’ duties, as it is an all female resident group. Key workers are allocated with consideration given to whether they ‘match’ the ethnicity, culture or background of the residents. Specialist support is sought as necessary such as psychiatrists, psychologists and epilepsy specialists. One resident was seen to have had regular breast screening and all had podiatry appointments (as necessary) and annual health check ups. 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 16 Staff were observed meeting personal needs as described in care plans (there were all agency staff on duty on the day of the site visit as the permanent staff were attending an induction.) The staff team demonstrated that they knew the needs of residents and were working consistently, according to the care plans. The home does not use controlled drugs and there are detailed guidelines for the use of medication prescribed to be used ‘as and when necessary’. The guidelines are approved by the G.P, and kept in individuals’ files and in a special file. The home uses the Boots monitored dosage system and whilst the pharmacist does not visit the home the manager audits the medication and procedures, regularly. Medication is always administered by two staff, who are only able to do so if they are deemed as competent. Competence is established by completing training and observation by a manager from another home. The manager also ‘spot checks’ staff in order to re-assess competence at irregular intervals or if there is any cause for concern. 20 Boadicea Close DS0000069484.V338961.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): People who use this service experience good quality outcomes in this area. The home protects the people who live there from all forms of abuse. It deals with complaints effectively even though it does not have a robust complaints procedure available, at this time. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home could not locate the complaints policy and procedure and there is not one available to residents or their family, at this time. One family member noted that there appeared to be no formal complaints procedure. The complaints book recorded, in detail the one complaint received since the last inspection, it detailed what action had been taken with regard to the complaint. One resident said that she knew who she would tell if she was not happy, a staff member described how he could tell if a non verbal resident was not happy and what steps he would take to see why. The new provider does have a written, formal complaints procedure and policy but it is not yet available in the home. The Commission for Social Care Inspection has received no information with regard to complaints or safeguarding adult’s issues about this service. The home has a Protection of Vulnerable Adults policy and procedure, including a copy of the local authority procedure, staff access training run by Slough County Council and a staff member was able to give a detailed response to how he would protect people from abuse. He was aware of the external agencies such as Social Services and the Commission and had received training in this area. 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 18 The home had referred one incident to the Local Authority as a ‘safeguarding adults’ issue, this had been referred and dealt with appropriately and all action had been taken to ensure, as far as possible that there can be no repetition of the incident. The home does not have a cross gender care policy to ensure the protection of residents, although staff are aware of good practice. Finance arrangements are in the process of transferring from the previous provider to the new provider, they are near completion. Residents have official rent contribution letters provided by the finance department who also act as appointees for all residents. Cash records are well kept and accurate, receipts are provided for all transactions. The provider should consider providing a receipt for the personal money that is, currently, held on behalf of the residents to ensure that delays with the bank and benefits agency transfer of financial arrangements does not impact upon them. Individual finances are not completely clear as yet, but the manager advises that they will be included on the agreement being developed for individuals. Behavioural guidelines for those who may have complex behaviours could be more detailed but one resident is aware of the guidelines and how staff will help them to deal with their behaviour. The home does no use physical interventions but staff are trained in any necessary techniques, all staff except two have completed appropriate training to help them to support any of the residents who may exhibit aggressive behaviours. 20 Boadicea Close DS0000069484.V338961.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): The people who use his service experience good quality outcomes in this area. The home makes sure that it provides a comfortable and clean environment to meet individual needs and enhance the lives of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The building consists of two bungalows connected by a central foyer, all necessary facilities are available in each bungalow. There are two bedrooms on one side and three bedrooms on the other, the bungalows can be self-contained or share facilities and the choices are generally made by the residents, such as use of showers or special baths. The environment is used flexibly, is very spacious and well maintained. Personal photographs and photographs of residents involved in events are displayed on the walls of communal areas. The bedrooms are highly personalised with all the necessary equipment to meet peoples’ diverse physical needs, provided. Bedrooms clearly reflect religion, culture and individual taste. 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 20 There are high standards of cleanliness and infection control. 20 Boadicea Close DS0000069484.V338961.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): The people who use the service experience good quality outcomes in this area. The staff team are competent and there are enough of them to meet the needs of the people who live there. The home provides opportunities for professional training and specialist training to enhance their skills to support individual residents needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a compliment of 14 staff the manager, the deputy manager and 12 care staff. Ten staff are full time and four are part time. Only one staff member has left in two years. The home has two vacancies, which are extra hours created to allow time for more daytime activities (not recruited as yet). Agency staff are used to cover shortfalls particularly with regard to one shortfall created by a long-term sickness. The manager advised that they try to use agencies that know the home and the residents, on the day of the visit there were three agency staff as the regular staff were at the induction with the new provider. One of the agency staff had been the acting deputy at the home for a year (in the past), the other two demonstrated that they knew the residents and their needs, the residents were relaxed and interacting with them very positively. Observation 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 22 of the mealtime showed that the agency staff were following the care plans and meeting peoples’ needs, as they preferred. There are three staff on duty as a minimum, this can rise to four for activities or other events. Male staff do not work alone, that is they work in the side of the home that has two staff on duty, female staff are always available to the all female resident group. Surveys described staff as ‘dedicated and professional’, ‘staff fine with residents best interests at heart’, there was one reference to staff morale being low, the manager felt that there was some low morale due to peoples misgivings about the unknown and change but that things were now ‘settling down’. The recruitment process is robust but the home does not have any recruitment paperwork, this is all held at the head office of Adepta. There is no check list or evidence that the necessary checks have been done to ensure staff are safe to work with the residents, the manager does not have access to references or application forms, at present. Staff training records showed that staff are up-to-date with mandatory training, the majority have completed Protection of vulnerable Adults, epilepsy awareness and other necessary training to enable them to respond to the needs of individuals in their care. Seven staff are qualified to NVQ 2 standard or above and three are pursuing NVQ qualifications, currently. The staff member spoken to felt that there were plenty of opportunities for training with the old providers and it appeared to be the same with the new ones, a calendar of training and training events was evident on the office wall and the manager has completed a training analysis for the home and for individual staff. 20 Boadicea Close DS0000069484.V338961.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): The people who use this service experience good quality outcomes in this area. The home is well managed and the residents are kept as safe as possible. The home has a system for looking at the quality of care it provides but this is not being used, at this time. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is currently pursuing her N.V.Q.4 in Care and Registered Managers Award, she expects to complete this in 2008.She has been managing the home for approximately two years. The home transferred from the Health Care Trust to the new providers on the 19th March 2007. The providers have a Quality Assurance system but this is not being used by the home, as yet. The home has regular regulation 26 visits and the manager confirmed that a report of the visit is kept in the home. 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 24 The manager said that the quality assurance system would be used when other priority areas of work had been completed such as making sure all policies and procedures are available and financial systems are finalised. The manager and staff team have worked hard to ensure that the transfer of the home has had little impact on the care of the residents although it has caused some disruption for administrative procedures, paperwork and policies. A sample of Health and safety records were seen, they are complete and upto-date. There are staff safe working practice risk assessments, general and specific for individual residents and medical device alerts, if relevant. The manager confirmed that Health and Safety works had been completed and was satisfactory and that Health and Safety training for individual staff is updated as necessary. 20 Boadicea Close DS0000069484.V338961.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 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 1 35 3 36 X 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 2 13 2 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 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 26 New Service 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 YA5 Regulation 5.1(b) (c) Requirement To develop a service user guide, which includes a contract/statement of terms and conditions for individual services users to ensure that they know what the home is providing for them. To ensure the complaints procedure is in the home and available so that anyone who may wish to use it is clear about how to make a complaint and what will happen when they have complained. To obtain the necessary recruitment documents and keeps them in the care home so that the registered manager can satisfy herself of the fitness of the staff to ensure the service users safety. Timescale for action 01/10/07 2. YA22 22 01/09/07 3. YA34 19 01/08/07 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 27 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. Refer to Standard YA12 YA23 Good Practice Recommendations To review the opportunities for service users to take part in fulfilling activities, suitable to their needs and to properly record such activities. To provide a cross gender personal care policy to ensure safe working practices for staff and service users. 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate 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. Extracts may not be used or reproduced without the express permission of CSCI 20 Boadicea Close DS0000069484.V338961.R01.S.doc Version 5.2 Page 29 - 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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