Inspection on 28/03/08 for 24 Tower Road West

This inspection was carried out on 28th March 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

24 Tower Road West 19/03/09

24 Tower Road West 10/02/09

24 Tower Road West 31/07/06

24 Tower Road West 12/01/06

24 Tower Road West 25/08/05

24 Tower Road West 26/01/05

24 Tower Road West 27/10/04

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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 24 Tower Road West St Leonards-on-sea East Sussex TN38 0RG Lead Inspector Caroline Johnson Unannounced Inspection 28 March 2008 10:15a th 24 Tower Road West DS0000021319.V359101.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 Tower Road West DS0000021319.V359101.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 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 24 Tower Road West Address St Leonards-on-sea East Sussex TN38 0RG 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) 01424 427607 East View Housing Management Ltd Sharon Kathleen Fisher Care Home 4 Category(ies) of Learning disability (0) registration, with number of places 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disabilities (LD). The maximum number of service users to be accommodated is 4. Date of last inspection 31st July 2006 Brief Description of the Service: 24 Tower Road West is a large Victorian house, rented for its services users by East View Housing Management Limited (EVH). The house has a wide hallway and there are two communal rooms on the ground floor. These include a large lounge area and a small dining room next to the kitchen. There is also an office and a downstairs toilet. There is one ensuite bedroom on the ground floor and there are three bedrooms, one bathroom and a toilet on the first floor. The third floor is office space for the Health and Safety Officer of EVH; the CSCI has been assured the office is always locked when not in use. The back garden is large and has an uneven terrain. However a newly installed decked area has been added which makes the garden area accessible to all residents. The house is in walking distance to the local shops, and is near the main bus route to Hastings and St Leonard’s on Sea town centres. The house is registered for four younger adults with learning disabilities. The home makes CSCI reports available to prospective residents and their relatives/representatives upon request. The gross weekly fee inclusive of income support is £948 to £1,242 as at April 2008. Residents pay for their own toiletries, hairdressing and magazines. 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at 24 Tower Road West will be referred to as ‘residents’. This key inspection included an unannounced site visit on 28 March 2008 and it lasted from 10.15am until 2.50pm. A second visit was made to the home to clarify some information as the manager was on leave at the time of the site visit. Over the course of the inspection there were opportunities to meet with three of the four residents and to meet with the manager and one member of care staff. A tour of the building was also provided. A range of records were examined including, care plans, records held in relation to staff training and recruitment, health and safety, quality assurance and minutes of staff and residents’ meetings. Since the last inspection a new manager has been appointed. The manager is also registered to manage another two homes owned by East View Housing. The home is currently recruiting for a deputy manager to assist the manager in her role. What the service does well: There is a warm and friendly atmosphere in the home. The frequency of staff and residents’ meetings ensures that everyone is kept up to date with changes in care practices and have regular opportunities to share their views. Residents have a varied programme of activities through the week and are supported to make use of local facilities at weekends. Residents are given the opportunity of having an annual holiday. The menus show that residents are offered a varied and well balanced diet. Monthly health and safety meetings are held which ensure that all maintenance issues are highlighted. Staff are provided with good training opportunities, which are relevant to working with people with learning disabilities. Residents stated that they are happy. Individual bedrooms have been personalised and residents stated that they chose the colour schemes they wanted. Residents have an annual holiday. 24 Tower Road West DS0000021319.V359101.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. 24 Tower Road West DS0000021319.V359101.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 24 Tower Road West DS0000021319.V359101.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. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents and their representatives are provided with detailed information about the home in order to make an informed choice about accommodation. Emphasis needs to be placed on ensuring that the information guide is more user friendly. EVIDENCE: There is a detailed statement of purpose in place, which is up to date. Each resident has a copy of the service user guide. The guide is presented using a widget format. It provides detailed information and attempts are made to explain difficult concepts. It is recognised that a lot of work has gone into developing this document however, because some of the issues contained are complex there is a concern that the document could be confusing and misleading to residents. Discussion was had with the manager who advised that at least two of the residents would probably prefer a written format, one a pictorial format and one would need the document explained to her no matter what format is used. 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 9 There was no pre admission assessment carried out in relation to the last resident admitted to the home. This was because it was seen as an internal transfer from one home within the company to another. It was confirmed that the resident had several tea visits, overnight visits and all day visits and that she eventually chose to move to the home on a temporary basis until she can move on to more independent living. Despite the fact that the company knew the resident, an assessment should have been carried out in terms of her compatibility with the other residents accommodated. The resident advised that she has settled in well and likes living at 24 Tower Road, but she is looking forward to living more independently. 24 Tower Road West DS0000021319.V359101.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): 6,7,8,9 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improved record keeping in relation to goal planning and ensuring that risk assessments are located in their individual care plan files would better promote residents’ health and welfare. EVIDENCE: There is detailed information in place in relation to reach resident. Two care plans were examined in detail and another two were partly examined. The quality of the information provided varied depending on who was responsible for keeping them up to date. Each resident had three to four files in place and this made it difficult to locate key information. The manager advised that the home is moving towards 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 11 having life plans with all information located in the one place rather than in the several files that are currently in place. In relation to files seen, one included very detailed information including the resident’s life story, information about things that are important to the resident and detailed information about the level of support required by the resident. There was evidence that the home had been having one-to-one meetings with the resident in the past but none had been held since 2006. There were no goals in place and no risk assessments. In relation to another resident there was very detailed information provided but it became apparent that the information was relevant to the resident’s previous placement and there was nothing to indicate if it was still relevant in the new setting. A one-to-one meeting was held with the resident’s keyworker within March 2008. There were no risk assessments in place. There were five goals in place. There was detailed guidance provided in relation to one of the goals in terms of what the resident can do and what aspects she might require support with. There was no guidance in relation to any of the other goals. In another care plan there were guidelines in place regarding a resident making drinks. The guidance was written in 2006 and there is reference to more detailed guidance being put in place once staff had a better understanding of the resident’s needs. This guidance has been reviewed since but no updates were made. Later in the inspection risk assessments for all the residents were found by chance in the communication book. Minutes of the last residents’ meeting were on display in the home. There was evidence that all residents were encouraged to have their say on issues that were important to them. One resident advised that she does not like one of her day care activities. The complaint procedure was explained to residents and they were asked if they had any concerns/complaints. A lit of activities/ day trips were agreed and in-house activities were also discussed. 24 Tower Road West DS0000021319.V359101.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents participate in a range of activities to meet their individual wishes and needs. EVIDENCE: Each of the residents has a programme of activities that they participate in. One resident is retired but follows a less structured programme of activities at home. She is occasionally encouraged to go shopping and have a day out. Activities in-house include jigsaw puzzles, board games, colouring and knitting. Three of the residents have structured programmes, which involve attending day centres on a full time basis. One of the three has a home day. One resident is independent with travel and can come and go as she pleases. Other residents are supported as necessary to make use of their local facilities. 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 13 Where there is family involvement residents are supported to maintain contact. During the inspection, one resident was busy making ‘thank you’ cards for family and friends following Easter. Three of the residents have chosen to go to Spain for their annual holiday. The fourth resident does not want to have a holiday but would prefer to have occasional days out. Residents are encouraged to participate in cleaning and laundry. It was reported that one resident is fully independent with her washing and ironing and is responsible for keeping her room clean. Other residents are supported where necessary with these tasks. The menu is on display in the kitchen area. In addition there is a menu using a widget system for one of the residents. The widget menu didn’t tie in with the other menu but staff said that they refer to the picture relevant to the day. Although this is a minor issue it could lead to confusion on the part of the resident and should be addressed. Menus seen were varied and well balanced. Residents spoken with stated that they enjoy the food served in the home. 24 Tower Road West DS0000021319.V359101.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): 18,19,20,21 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of risk assessment around the subject of self-medication could potentially place a resident at risk. The home’s policy on medication needs to be available for reference. EVIDENCE: One resident has a goal plan in place to self-medicate. No risk assessment has been carried out and it is not clear how much of the process the resident carries out independently. A staff member advised that staff guide the resident to take the medication out of the blister pack and when she has taken it the resident then signs the mar chart. Some staff have signed the goal plan indicating that this task has been completed independently. However there is some uncertainty about what this actually means. 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 15 The home’s policy on the administration of medication is not stored in the policy manual but reference is made in the manual to the location of the manual at the local office. In the house office there are guidelines that have been drawn up by the home’s pharmacy. However, the manager advised that the home’s policy is included in the staff handbook. It is therefore not clear which document staff should refer to in respect of medication. A staff member advised that staff have to complete a medication proficiency test before they are assessed as competent to administer medication. Records show that when specialist advice is required then the home makes arrangements for this to happen. Information in the care plans with respect to chiropody and weight monitoring is not up to date but a staff member was able to show in the diary that residents receive regular chiropody and their weights are monitored monthly. There is one exception to this as one resident always refuses to be weighed. It was noted that another resident has gained a lot of weight in the past few months. The resident is new to the home and the manager advised that the resident would be supported with this issue. A staff member observed in the course of their duties was courteous and friendly and was on hand to meet the many requests for assistance from the resident in the home at the time of inspection. There is no reference in care plans to the wishes of residents in relation to dying and death. The manager advised that the majority of the residents don’t want to talk about the subject. This is not documented. The manager has also talked to some of their relatives about the subject and needs to record the outcome. 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems in place encourage residents to share any concerns they might have and to know that they will be dealt with. EVIDENCE: There is a detailed complaint procedure in place. The last complaint recorded was in 2004. However, it was noted that the document still includes the old address for the Commission. There is a complaint procedure available in a widget format. It was also noted that the residents are reminded at the residents’ meeting of the complaint procedure and given the opportunity to share any concerns they might have. The policy on the protection of vulnerable adults was in place but did not include information such as what would happen if an allegation were to be made. The manager advised that the policy has since been updated and will be sent to the home. The manager confirmed that she has attended training on the subject of adult protection. Most of the staff team are fairly new in post and as part of induction the subject of adult protection is covered. There is also an in-house 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 17 training video on the subject. Further formal training will be provided in the coming months. 24 Tower Road West DS0000021319.V359101.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, 25,26,27,28,30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from living in a clean and homely environment where they are able to personalise their own rooms. The planned refurbishment of the property will be of benefit to the residents. EVIDENCE: East View Housing is in the process of purchasing 24 Tower Road West, which has previously been rented. There are a number of areas within the home that are in need of redecoration in particular the kitchen and dining room. It was reported that upon successful completion of the purchase a programme for the refurbishment of the property would begin. The ground floor bedroom has been redecorated since the last inspection and a new ensuite assisted bath has been fitted. The resident occupying this room advised that she is very happy with her new room and that she chose the 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 19 colour scheme. All bedrooms seen had been personalised and reflected the individual tastes and personalities of the residents. It was also reported that the lounge area has recently been repainted. To the rear of the property a new decking area has been installed, which overlooks the garden area. It gives the appearance of an additional room off the dining area and will be of great benefit to the residents during the summer months. It was noted that the sash cord is broken on the window in one of the bedrooms and a wooden box had been put in place to hold the window open. This presents a risk both to the resident and to staff. All areas of the home seen during the inspection were clean. There is a cleaning rota in place for staff, which ensures that all cleaning tasks are carried out on a regular basis. 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are provided with good opportunities to update their skills and knowledge and this enables them to meet the needs of the residents accommodated. EVIDENCE: There has been a high turnover in the staff team since the last inspection although since the appointment of a new manager this has been more stable. The rota seen included several shifts that were required to be covered within the month. However, a new member of staff was due to start in post. Records were in place showing the staff training that had been held in the early part of the year. The manager advised that all staff were up to date with mandatory training. The manager also confirmed that all staff would attend a course on mental health awareness and managing relationships. The majority of the staff team have received training on dementia. 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 21 It was reported that the frequency of staff supervisions have slipped in recent months. This should improve once a deputy manager has been employed. Another strategy taken by the home to address this area is that supervisions are now booked to be carried out when staff are on duty. The procedure prior to this was that staff would come in early or stay on late for supervision and this often caused problems. A staff member confirmed that they completed the company’s induction, which took a morning to complete. Following this they have recently completed the LDAF (learning disabilities award framework) and are currently waiting for this to be signed off. Another staff member has recently completed LDAF and another is due to finish soon. On completion of LDAF staff then go on to do NVQ training. Records seen in relation to recruitment showed that thorough procedures had been followed. 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,42,43 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The wedging open of fire doors presents significant risks to residents if there were to be a fire. The owners must demonstrate that they are monitoring the running of the home. EVIDENCE: The registered manager is responsible for the management of three homes within the company. She took over management of Tower Road West in August 2007. The company is actively recruiting for a manager to assist her in this task. Staff spoken with described the manager as ‘very supportive’. 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 23 Staff meetings are held on a monthly basis. Minutes were seen in relation to the last three months and they show evidence that staff are encouraged to have their say on the running of the home. In relation to quality assurance it was noted that satisfaction questionnaires were sent to residents and their relatives in February. The responses were sent to the local office in error and the manager confirmed that they would be returned, responses collated and feedback provided to all relevant people. The home has accreditation with Investors in People. The manager also advised that there is a SWOT (strengths, weaknesses, opportunities and threats) meeting held annually. This involves a person semi-independent from the company meeting with senior managers, managers and deputies, support workers and then with residents to gain feedback on the various issues relevant to each group. Feedback is provided to each group on the outcome of the meetings. Prior to the inspection surveys were sent to the home for distribution to residents. Two surveys were returned. Both surveys were positive. One resident responded positively to all questions and stated I’m happy’. The second resident also responded positively to all questions with the exception of one, where she was asked ‘do carers listen and act on what you say’ she responded ‘sometimes, but not if they are busy’. It was noted that monthly visits carried out by the Responsible Individual or a representative on their behalf have not been carried out for some time. The manager advised that they have had senior manager support and she meets regularly with the other managers from within the company. In addition the health and safety representative carries out a property inspection on a monthly basis and a report is forwarded to the owners. The home’s policy and procedure manual was examined and it was noted that several of the policies were missing and there was a statement advising staff to refer to the local office for the policy. The manager advised that the company are in the process of putting all the policies and procedures on disc and that this would meant that staff will have access to them from the home at all times as all staff are computer literate. The annual development plan was not examined at this was at the local office. In relation to health and safety there were a number of certificates in place showing that equipment had been serviced and tested at regular intervals. In relation to fire safety it was noted that there had been a fire drill recently and detailed records were kept of the outcome. Water temperatures are tested and recorded on a monthly basis. As stated previously a health and safety assessment is carried out monthly and minutes of the last assessment highlighted a number of areas where minor maintenance works are required. 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 24 Doors are wedged open in the dining room and lounge area. This was discussed with the manager who advised that one resident in particular would not cope with the doors being kept closed. The dining room door is not currently a fire door. The manager advised that there are plans to replace the dining room door, with a fire door, as part of the refurbishment of the building. The home was asked to complete a risk assessment around the use of the door wedges and to take appropriate action taking into account the wishes/needs of the residents. 24 Tower Road West DS0000021319.V359101.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 2 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 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 2 3 3 2 2 X 2 3 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 Requirement Timescale for action 30/06/08 2. YA20 3. YA20 4. YA21 5. YA24 6. 7. YA36 YA39 In relation to care planning, goals set for residents must be specific, measurable and achievable. Advice must be included on how this can happen. 13(2)(4a,c) A risk assessment must be carried out in relation to the safety implications of one resident self-administering her medication. 13(2) The home’s policy on the administration of medication must be available for staff to refer to. 12(3) As far as it is possible to the wishes of residents in relation to dying and death must be assessed and recorded. 23(2b) Timescales for the upgrade of the property must be sent to the Commission and they must include reference to the refurbishment of the kitchen, dining room and the sash cord on one of the bedroom windows. 18(2) All staff must receive regular supervision. 26 The Responsible Individual or a DS0000021319.V359101.R01.S.doc 30/04/08 15/05/08 30/06/08 31/05/08 15/05/08 30/04/08 Page 27 24 Tower Road West Version 5.2 8. YA42 23(4a) representative on his behalf must visit the home unannounced and carry out a report of the findings. The outcome of the report must be copied to the manager and be available for inspection. Fire doors must not be wedged 30/04/08 open. Risk assessments must be carried out to determine safety implications of having fire doors kept closed and if the risks are too high then appropriate measures must be taken to safeguard against the risk of fire. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA1 YA2 YA9 YA40 Good Practice Recommendations The home’s service user guide should be available in a format that is suitable for the residents. A pre admission assessment should be carried out for all prospective residents. Risk assessments should be located in individual care plans to ensure that the information is accessible to all staff. The home’s policy and procedure manual must be complete, up to date and available to staff. 24 Tower Road West DS0000021319.V359101.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office 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 24 Tower Road West DS0000021319.V359101.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. 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!