Inspection on 24/11/06 for 24 Bowens Field

This inspection was carried out on 24th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

24 Bowens Field 11/01/06

24 Bowens Field 21/06/05

24 Bowens Field 02/02/05

24 Bowens Field 24/11/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 24 Bowens Field Wem Shrewsbury Shropshire SY4 5AP Lead Inspector Deborah Sharman Unannounced Inspection 24th November 2006 09:00 24 Bowens Field DS0000020736.V316076.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 24 Bowens Field DS0000020736.V316076.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. 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 24 Bowens Field Address Wem Shrewsbury Shropshire SY4 5AP 01939 236517 NONE 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) Loppington House Limited Hilary Evans Andrea Minton Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11 January 2006 Brief Description of the Service: 24 Bowens Field is registered with the Commission of Social Care Inspection (CSCI) to provide accommodation and care for three people with a learning disability. The home is situated in a suburban area of Wem. Loppington House Ltd owns the home and the Registered Provider is its Director, Mr Paul Harris. Hilary Evans and Andrea Minton are the joint Registered Managers of Bowens Field and Loppington House. The three people living at 24 Bowens Field previously lived at Loppington House and were chosen carefully for their compatibility. They were fully involved in the resettlement process, choosing decoration, furniture and fittings prior to moving in during a period of gradual introduction to the home. The purpose of the home is to create as normal a lifestyle and environment as possible for its residents and this is achieved. Three days in the week the service users are able to access a workshop and retail outlet owned by Loppington House Ltd where they gain experience in every aspect of the business, one days a week are dedicated to learning life-skills in the home and one day per week is a free choice activity of either horse riding, swimming etc. The service users are fully integrated into the local community and they have the use of a vehicle in addition to public transport for leisure activities and holidays. The weekly charge ranges from £865.87 to £938.21 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was Bowens Field’s first inspection of this inspection year. This was a key inspection meaning that all key Standards were assessed in order to judge the home’s performance. This inspection which was carried out by one Inspector over a seven hour period from 9.00 a.m. was unannounced meaning that no one associated with the home received prior notification of inspection and were therefore unable to prepare. The quality of service provision was assessed in a variety of ways: through assessment of key documents including looking in detail at care provided to one service user, a tour of the premises and through brief discussion with a staff member before she went off duty. The Inspector was also able to interview the service user whose care was assessed in detail. This service user expressed satisfaction with all areas of care and said that s/he was ‘happy’. The Inspector was able to briefly chat with all three service users upon arrival at 9.00 am whilst they were waiting for transport to take them horse riding which they were all looking forward to. Upon return from day activity the Inspector met a second service user on a one to one basis. This service user presented as calm and contented but is non-verbal and was therefore not able to answer questions about his / her experience of living at Bowens Field. A third service user did not return home from day activity during the inspection period and was therefore unable to contribute. Both newly registered joint managers were available to support the inspection from 10.00am when a staff member notified them of the Inspector’s arrival. Prior to inspection the Commission for Social Care Inspection sought the views of relatives, professionals and service users about the quality of service provided at Bowens Field. A response was received from one relative and a GP and all comments from both were very positive. Service users pre inspection comments were positive too with the exception of knowing how to make a complaint but Managers commented that the nature of the questionnaire made this difficult concept difficult for service users to answer. There have been no incidents, accidents, complaints or allegations at or about 24 Bowens Field since the last inspection. Inspection outcomes show that staff and Managers at Bowens Field continue to provide a good service with all Standard groups scoring at or above ‘good’. It is judged therefore that service users are safe, happy and receiving a service that appropriately meets their needs. 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Some areas for improvement were identified at this inspection. 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 7 Training although judged good overall is the weakest area of performance where the greatest improvement is required to ensure that all staff receive all mandatory training to equip them to fulfil their job role. Care planning requires developing in scope to ensure all service user needs are included. Service users, subject to risk assessment would benefit from the provision of internal door locks to private space for the protection of privacy and dignity. Staffing levels are judged to be safe given the low dependencies of service users. However current lone working arrangements are not risk assessed and restricts service user choice and dignity to some degree. A robust quality assurance tool is required to support the managers to self assess the home’s performance and to facilitate a response to service quality issues. 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. 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 8 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 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. There have been no admissions to Bowens Field since 2000 when the home opened. Recent practice therefore cannot be assessed. However policies and procedures remain the same and the Managers demonstrated a good understanding of processes to follow to ensure that service users are appropriately admitted to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Current performance cannot be assessed, as there have been no new admissions to the home since it opened in 2000. However policies and procedures for admission have not changed, were available on the premises and were known to the new Managers who were involved with the initial admissions to the home. 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good overall. Care plans are based upon assessed risk, and service user ability and care is reviewed well. Although care plans that are available are good there are some significant omissions, which provide the potential for omissions in care. However given that no omissions in care outcomes were identified for the service user whose care was assessed, the overall rating is judged to be good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Available care plans are good. They are well structured, contain a good level of detail, are based upon assessed risk, and are reviewed and amended when there has been deterioration and progress. Care plans are based upon service user abilities which is good practice and have been signed by the service user to whom they relate. Multi disciplinary reviews are taking place too and are evidenced well with good minutes. 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 11 Care plans are not in place to meet all areas of service user need. For one service user some omissions are epilepsy management, dietary preference, family contact and financial arrangements and decision making. Although there was no evidence of omissions in care provided to services users as a result, with insufficient guidance this remains a potential risk. A range of appropriate and individual risk assessments are in place with control measures to reduce the risk from identified hazards. From observation service user choices are respected on a day-to-day basis and advocacy systems are in place to support service user rights and choices. 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Quality in this outcome area is generally good. A wide range of activity and community access that complies with the service users known interests is provided. Staffing provided more flexibly would enable individual rather than group activity, which is particularly important in order to address gender differentials. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A wide range of different day opportunities are available that provides a varied and interesting week for service users based upon their assessed preferences. Contingency arrangements are in place should service users not be able or not want to attend planned day care offering choice and flexibility. Care plans for daytime activity have been changed and implemented at a service users request. A service user has enjoyed two holidays this year, one being a themed activity holiday in response to her known interests. 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 13 Where service users have fixed arrangements for family contact this is recorded in their care plan and visits are evidenced in the visitor’s book. But where family contact is none existent or complex this is not included in a plan of care to guide staff. Staff could be provided more flexibly. The home is single staffed which means that all residents have to go out together at weekends and evenings. Two staff are provided occasionally to support a group activity out. But lone working staffing prevents service users choosing not to go out or restricts the service user from pursuing an activity on their own with a staff member. For example, one service user whose gender differs from all other residents was keen to buy underwear at the weekend. All three-service users would have to do this together because of lone working arrangements. Although the Inspector was told that service users have never objected, this does not proactively manage dignity issues that arise from diversity. There was no evidence however at this inspection that the service user case tracked had had to be follow pursuits not of his / her choosing due to lone working. Lack of assessment of dietary preferences, lack of documentation evidencing service user food intake combined with menus that don’t stipulate alternatives, meant it was not possible to evidence that service users are provided with meals of their preference and choice. A menu based upon the Standard menu is available for ‘dieters’ but there is no evidence that this has been adhered to. Managers gave verbal reassurance that choices are offered but this could not be verified. A service user was able to tell the Inspector however that the meals are ‘nice’ 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. Personal care is provided according to service user need and ability with independence being encouraged. All required health screening had been provided to the service user whose care was inspected. This would however, be better managed, monitored and evidenced by an improvement in record keeping for health care outcomes. Medication is well-managed maximising health and minimising risk to service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspector was able to evidence that a service user had been provided with all health screening required e.g. psychiatric review, three monthly health check with the GP, blood tests to monitor a known condition, dental, optical and sexual health screening. The system of record keeping for health appointments however is poor and requires review to help the home to monitor health screening provided. Improvements in dental health were evidenced as a result of adherence to the plan of care evidencing obvious health benefits for the service user. 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 15 All service users present as exceptionally well groomed with individual style. Care plans available to staff to guide the provision of personal care are excellent. The extent and limitations of personal Care is determined according to the ability of the service users who are encouraged to be as independent as possible. Privacy would be better protected with the provision of appropriate internal locks on bedroom doors. Finance records evidence the provision of hair dressing services. Medication was assessed and is well managed. Medication Administration Records and medication stocks tally with plans of care and records evidence that medication is reliably administered. Guidance has been sought and received from the GP in respect of the administration of homely remedies. Most staff that administer medication have received appropriate training. Two new staff who work alone and unsupervised are administering medication whilst awaiting medication training. Steps have been taken in the meantime by the Managers to limit risk. There is documented evidence of in house training and assessment of competence to administer. 24 Bowens Field DS0000020736.V316076.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): Quality in this outcome area is excellent. There are sufficient policies and procedures in place to guide staff and Managers. Furthermore, Managers are well aware of action to take to protect service users. Service users are additionally protected by safe recruitment practices, safe financial management that protects service users interests and staffing levels which are currently considered to be sufficient. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection there has been no change to policies and procedures, All of which were available on the premises and available in accessible formats. There have not been any complaints about the service to the Provider of care or to the Commission for Social Care Inspection. There have neither been any accidents, incidents, allegations or staff disciplinary action. Staffing levels are currently considered to be safe given the low dependencies of service users. Managers have prior experience of adult protection procedures through an Incident unconnected with Bowens Field and were able to verbalise a good Understanding of the extent and limitations of their role in the event of an incident or allegation. Money which is generally managed on service users behalf is available to service users and the system for its management protects and safeguards service users financial interests 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 17 All staff and both registered managers with the exception of two new staff are trained in adult protection matters and plans are in place for the two new staff to undertake this. 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30. Quality in this outcome area is good overall. The premises meet service users needs, are homely, exceptionally clean and very well finished and maintained. Sufficient locks to maintain privacy have not been provided but Managers demonstrated a commitment to addressing this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Accommodation provided is homely, domestic in style and in keeping with the residential area where it is located. It is well maintained and decorated and finished to a high standard. Maintenance and repairs issues are identified in monthly audits and are acted upon. In addition the home is spotlessly clean, fresh smelling with a low risk of cross infection given the low dependencies of service users. All hazardous products are locked safely away. 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 19 The appropriateness of the premises has been considered in relation to service users needs e.g. the provision of the only ensuite room to the only female resident in the group and the allocation of the only ground floor room to a service user who has epilepsy. The Inspector observed one service user holding and using a key to their bedroom. The Inspector was told that this service user likes to lock the bedroom door as another service user is known to enter. Action therefore must be taken subject to risk assessment to address the lack of locking facilities on internal bedroom doors. In discussion the service user case tracked was very enthusiastic about the possibility of the provision of additional locks and indicated that the maintenance man would do it. This will better protect service users privacy and dignity. Laundry has to be carried through a food preparation area as laundering facilities are in the kitchen which is common to properties domestic in style. However protective equipment is available and a recessed area of the kitchen provides some delineation from the food area. Service users personal dependencies are low and therefore the risk of cross contamination is thought to be low. 24 Bowens Field DS0000020736.V316076.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): Quality in this outcome area is good. Staff are well supervised and a staffs training system is in place that must now address identified omissions in training provided to staff including induction, NVQ and other mandatory learning. Recruitment processes are generally safe but advice was given to ensure risk is always minimised. Staffing levels are judged to be safe but inflexible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Sixteen percent of care staff currently hold an NVQ award. This falls short of the 50 national target which will have been met when current candidates successfully completed their training. Induction for new staff is not being provided to the required standard as this Has been overlooked in favour of starting candidates on an NVQ programme. The Manager said that she will ensure that all new staff now receive Appropriate induction as she now appreciates that this is a necessary precursor to NVQ. An up to date training matrix is in place that identifies omissions in training 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 21 provision. Managers are aware of significant omissions in training such as moving and handling, infection control, health and safety, epilepsy awareness and are beginning to address these. Certification shows a new Staff member to have undertaken training in challenging behaviour management, fire awareness and first aid. Recruitment checks were assessed for one new staff member and a volunteer. From the records sampled it is clear that all checks had been obtained prior to Commencement in employment. Discussion however showed that some staff have started with a POVA first check prior to receipt of a full Criminal Record Bureau check and without risk assessment. Managers were advised that this practice must only happen in exceptional circumstances and only subject to full written risk assessment. There is good evidence of regular, structured and well-recorded staff supervision demonstrating that managers are providing suitable support to staff to enable them to fulfil their job roles and meet service user need. Good systems are in place for management support to staff during out of office hours. A staff member told the Inspector that someone was always available to them. A lone worker who had reported sick whilst on shift the night before inspection had been covered without delay and was able to go home. Staffing levels are currently safe given the low dependency needs of service users who do not require support to manage behaviours. Therefore a requirement has not been made. However a recommendation has been made to review staffing arrangements under Standard 13 to try to achieve a more flexible approach given that lone working does not optimise service user choice, individuality and diversity. 24 Bowens Field DS0000020736.V316076.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): Quality in this outcome area is generally good There are some important areas identified for improvement e.g. quality assurance and the supervision and appraisal of the newly Registered joint Managers. But on a day-to-day level lack of formal supervision has not negatively influenced outcomes for service users, which remain good. This home has a good record of compliance, therefore CSCI is confident that omissions identified will be promptly addressed. The service is therefore considered to be safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The two newly registered joint Managers are very experienced with the service user group having worked for this company for 23 and 13 years respectively. This is their first post and first inspection as registered managers however. The Managers have both undergone minimal training this year as they 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 23 explained they have been ‘getting to grips with new post’. They have both however completed` a range of relevant training and intend to continue to keep their training up to date. One manager is appropriately qualified to the required minimum national level and the other is partly qualified with firm plans in place to ensure full compliance with required qualifications. Both managers are arms length managers, not being based on the premises but are ‘always available’; visit when on call and once per week. A team leader is responsible for day-to-day operational issues. Both managers who do not have job descriptions for their new role have received no supervision since being appointed to this role eight months ago but feel that their supervisor is always available to them. This does not appear to have negatively impacted upon outcomes for service users but must be addressed to support the ongoing development of the managers and the service. The team leader facilitates staff team meetings. They are attended by service users, are regularly held and are well-minuted showing consultation with staff, direction and service user focus. All maintenance documents are up to date. Gas appliances have been serviced and are evidenced but a Gas Landlord certificate has not been provided. COSHH assessments are not in place for the 2 products randomly sampled and only data sheets are available for all other products. All fire safety systems were satisfactorily evidenced and the recent recommendations of the fire officer have been actionned. All staff except one have had fire training with a plan in place to provide training for the staff member who missed previous training. Fire drills and tests are well evidenced. All staff with exception of one have first aid training and again a plan is in place to provide training where it is required in January 2007. The Inspector was told that it has been many years since Environmental Health carried out a Food Safety inspection. Cold food storage temperatures are not being recorded and monitored nor hot food temperatures. This does not protect service users from the risk of food borne illness and does not demonstrate that the service is doing all it can to minimise associated risk. From discussion there appear to be some systems in place to support quality review e.g. evidenced monthly visits by the Provider, service user reviews, advocacy meetings, staff meetings attended by service users, complaints and compliments and monthly health and safety visits (although these could not be evidenced as records are kept at Loppington House). All these systems are disparate and not drawn together into a robust quality assurance system which 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 24 evidences on going development and improvement based upon rigorous assessment and feedback. During the inspection the Managers identified for themselves how a robust quality assurance system would have helped them to identify some of the areas identified at inspection for improvement. Staff are lone working without recourse to a lone working policy or without the circumstances having been risk assessed. However there have been no incidents affecting the welfare of service users, no accidents, no allegations, no complaints, no staff disciplinary action and no hospitalisations. These factors are combined with good health screening, good staff recruitment processes, robust protection procedures and staffing levels appropriate to current service user need. On this basis 24 Bowens Field is considered to be providing a safe service. . 24 Bowens Field DS0000020736.V316076.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 3 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 4 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 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 2 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 26 None made. 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 YA6 Regulation 15 Requirement The Registered Managers must ensure that care plans are in place to meet all areas of identified need for all service users. Requirement arising from inspection, November 2006. The Registered Manager must ensure that records are maintained of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for the individual service users. Timescale for action 31/01/07 2 YA17 17(2) Sch 4(13) 31/12/06 3 YA26 13(4) 23(1)(a) 12(4a) Requirement arising from inspection November 2006. The Registered Managers must, 31/12/06 subject to risk assessment and in consultation with service users, ensure that appropriate locks are fitted to bedroom doors to ensure that they can be locked by service user/s from the inside. DS0000020736.V316076.R01.S.doc Version 5.2 Page 27 24 Bowens Field Decisions not to fit such locks must be accounted for within recorded risk assessment. New requirement arising from inspection November 20006. The Registered Managers must 30/06/07 ensure that all persons employed at the care home receive all training appropriate to the work they are to perform including structured induction training to the required national standard, NVQ and all other mandatory training. New requirement arising from inspection November 20006. The provider must ensure that the Registered Managers are appropriately supervised, that this is evidenced and that records are available for inspection. Each Manager must receive a minimum of 6 supervisions in every 12 month period. New requirement arising from inspection November 20006. The registered person shall establish and maintain a system for evaluating the quality of the services provided at the care home. The system referred to must provide for consultation with service users and their representatives. 7 YA42 13(4) 23 The Provider must provide a written statement (based upon risk assessment) of the policy and arrangements for maintaining safe working practices in relation to lone DS0000020736.V316076.R01.S.doc 4 YA35 18 5 YA37 18(2) 31/12/07 6 YA39 24 28/02/07 31/12/06 24 Bowens Field Version 5.2 Page 28 working. A Gas Landlord certificate must be obtained and retained to evidence Gas safety service maintenance. Full COSHH assessments must be carried out based upon data available for all hazardous products stored on the premises. Subject to advice from Environmental Health Food Safety Department, cold food storage temperatures must be taken and recorded twice per day and corrective action must be taken if temperatures do not comply with safe temperature ranges. Subject to advice from Environmental Health’s Food Safety Department, hot food temperatures must be taken and recorded prior to serving to ensure the safety of food served. New requirement arising from inspection November 20006. 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 YA13 Good Practice Recommendations The Provider should review the numbers of staff on duty to ensure that staff time with and support for service users outside the home is flexibly provided (e.g. particularly in respect to privacy and dignity issues / gender differentials / to actively promote real choice) The Registered Managers should be provided with a job DS0000020736.V316076.R01.S.doc Version 5.2 Page 29 2 YA37 24 Bowens Field description to ensure compliance with NMS 37 and 31. 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 24 Bowens Field DS0000020736.V316076.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!