Inspection on 31/01/06 for 25-27a Alexandra Road

This inspection was carried out on 31st January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

25-27a Alexandra Road 27/11/07

25-27a Alexandra Road 12/06/06

25-27a Alexandra Road 02/06/05

25-27a Alexandra Road 16/03/05

25-27a Alexandra Road 07/09/04

25-27a Alexandra Road 27/01/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Alexandra Road (25/27a) Weymouth Dorset DT4 7QQ Lead Inspector Stephanie Omosevwerha Unannounced Inspection 31 January 2006 10:45 st DS0000032045.V281850.R01.S.doc Version 5.1 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 DS0000032045.V281850.R01.S.doc Version 5.1 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. DS0000032045.V281850.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Alexandra Road (25/27a) Address Weymouth Dorset DT4 7QQ 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) 01305 760663 01305 770236 Dorset County Council Daniel James Crone Care Home 23 Category(ies) of Learning disability (23), Physical disability (3), registration, with number Sensory impairment (2) of places DS0000032045.V281850.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing levels must be those determined in accordance with guidance recommended by the Department of Health. 2nd June 2005 Date of last inspection Brief Description of the Service: 25/27a Alexandra Road is a care home providing a service to adults who have a learning disability. The home is located in Weymouth, a short distance from the town centre, and is owned and operated by Dorset Social Care and Health Directorate. Alexandra Road was built in the late 1970s and can accommodate up to 23 people, usually offering 21 permanent and 2 short-term care places. The home is split into units, accommodating between 4 and 9 service users in each unit. Each unit has a lounge, dining room, kitchen and their own bathroom and toilet. Each service user has a single bedroom. The home has special adaptations and equipment to meet residents various physical needs. These include ground floor bedrooms, walk in baths and adapted toilets. There is level access to the building. There is a garden to the rear of the property. Staffing is provided 24 hours a day and as well as providing personal care and support, service users are encouraged to be part of the local community by taking part in leisure and social activities. DS0000032045.V281850.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over approximately 6 ½ hours. It was the second annual inspection carried out as part of the planned inspection programme for care homes undertaken by CSCI. The inspection also addressed the requirements and recommendation that were made at the previous inspection. The initial part of the inspection was spent with the manager and 2 senior members of staff. The inspector examined records and documentation including service user files, staffing records, and medication records. A tour of the premises was carried out consisting of all communal areas and a sample of residents’ bedrooms. The inspector was able to talk to 2 members of care staff and then spend time with all the residents on their return from their daytime activities. Further information held at the CSCI office including previous inspection reports, reports of monthly monitoring visits (R.26) and the home’s statement of purpose was also taken into account when compiling the report. What the service does well: Alexandra Road is well run and managed by an experienced team whose roles in the home are clearly set out. This ensures all aspects of life in the home are effectively covered. There is an atmosphere of openness and service users and staff are encouraged to discuss their views on how the home should be run. The home has a committed staff team who work hard to ensure improvements are made to residents’ quality of life. Staff work with small groups of service users who they get to know very well. This ensures excellent continuity of care providing residents with a good level pf personal care and support, which respects their personal preferences. Observation of practice in the home showed that staff spent most of their time with service users and it was clear good relationships had been formed. Staff spoken with enjoyed their work and felt well supported resulting in an enthusiastic workforce. Residents spoke positively about their care and were particularly enjoying the new opportunities to spend more time in the home doing the activities of their choice. Although Alexandra Road can accommodate up to 23 residents, the premises comprises of four different living units with between four and nine service users accommodated in a unit. Each unit has a small kitchen, dining room, lounge and bathroom and this gives the environment a homely feeling. There is a pleasant garden and service users have recently enjoyed a project working outside as part of their daytime activities. DS0000032045.V281850.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The home needs to ensure a care plan is set up for all residents including new residents. This can then be amended and reviewed as necessary. The homes systems of storing and recording information could be better improved particularly by archiving/filing things that are old and out-of-date. This would give a much clearer picture of the resident’s current needs. It would also highlight when reviews were needed as some care plans and risk assessments had not been reviewed for over a year. The home recruitment procedures were not as robust as they should be at the last inspection. However, as no new staff had been recruited since the previous inspection the inspector was unable to assess if improvements had been made. There were still some gaps on staff files in obtaining proof of identity such as photographs and birth certificates and this will be assessed again at the next inspection. The home needs a need policy concerning the administration of medication to ensure all aspects of managing service users’ medicines are covered. The home also needs to develop a plan monitoring the quality of the service it provides based upon seeking the views of service users and other interested parties, to ensure success in achieving the aims and objectives of the home. DS0000032045.V281850.R01.S.doc Version 5.1 Page 7 The inspector observed that some of the décor was a little tired looking with wallpaper being torn in one or two places. Some parts of the home would benefit from being redecorated. Some of the furniture is also showing signs of wear and tear and would benefit from replacing. The home continues to offer a respite service despite the fact the communal areas cannot be separated from the living areas of the permanent residents This, therefore, has a negative impact on the permanent residents living in the home. 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. DS0000032045.V281850.R01.S.doc Version 5.1 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 DS0000032045.V281850.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Improvements had been made in obtaining information about prospective residents to ensure the home can meet their needs. Further development needs to be done to ensure the home makes its own plans of how it is going to support and work with new residents. EVIDENCE: The home has clear admission procedures that are set out in the statement of purpose. The home provides care for people with learning disabilities and also caters for those who have additional needs such as physical disabilities and sensory impairments. There had been one new admission to the home since the previous inspection and the service user’s file was examined as part of the inspection. There was evidence that a care management assessment and plan had been received and further information was available from other healthcare professionals. This meant the home was able to establish that they would be able to meet the service users needs. The home had not yet developed a care plan for this resident who had been admitted in December 05. The manager said this was because initially they had been unsure whether the service user would become a permanent resident and they were still in the process of getting to know their needs. A plan needs to be set up which can then be reviewed as necessary according to any changes in the service user’s needs. DS0000032045.V281850.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. The home’s system of care planning would be improved by better organisation of files to ensure the most current information is more prominent. This would also highlight when reviews are needed to ensure these are kept up-to-date. Recent increases in staffing hours had meant that service users had more opportunities to make decisions and choices about their daily lives. Some progress has been made in reviewing risk assessments, however, further reviews are needed to ensure up-to-date information is available. This will help identify if training in personal safety can be given to avoid limiting service users choices. EVIDENCE: A sample of 2 permanent residents’ and 1 new resident’s files was viewed. Each resident has a file that is kept in the office, a working file is also available to staff that contains the most recent care information and risk assessments. The office files contain all information held about each resident and the inspector noted that some information dated back to 1984. It is recommended DS0000032045.V281850.R01.S.doc Version 5.1 Page 11 that this information be archived so only current information is contained in the files. This will make it much easier to find the most up-to-date information. Each file contained a document called “Establishment Task List”. This contained information about personal hygiene, toileting, mobility, eating and drinking, sleeping, social and therapeutic activities, health, safety, communication, opportunities and self-care. The home currently uses this document as the care plan. There was no evidence that these had been recently reviewed, the last recorded review on one file was January 2004. An individual service plan was available which was reviewed each year and included all services that the resident was involved with such as the Day Centre. This document gave details of the residents’ needs and strengths and individual goals. There was further evidence that resident’s had recently been consulted about their daytime preferences and this information had been added to their working files. Discussion with the management team and staff indicated that there was a good working knowledge of service users’ needs. Staff work in small teams with the same groups of service users so get to know their needs well. Discussion with service users and observation of practice showed that residents felt positive about their care and confident their needs would be met. The manager told the inspector that the staffing hours had been increased by 200 hours per week. This meant that service users now had more opportunities to stay home during the day and make choices in their daily lives. Observation during the inspection showed that two service users were supported to go out into the community and another service user was supported to go on a day trip of their choice. Service users were also supported to prepare their own lunch and had a choice of their evening meal. Discussion with residents confirmed they were able to make decisions such as visiting the local shops, visiting their families and what they did during the evening. A recommendation was made at the last inspection that risk assessments need to be clearer with more evidence of how decisions were reached. There was no evidence that the risk assessments on individual files had been reviewed since the last inspection. The manager said they were up-dating risks as they occurred and showed the inspector a risk assessment for the service user who had gone on a day trip that day. The new format provides clearer information, however, risk assessments on individual files still need to be reviewed to ensure they are appropriate and do not potentially limit service users’ choices. DS0000032045.V281850.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Additional staffing hours have meant the home is able to offer a greater range of activities, which has given service users more flexibility and choice increasing their access to the local community. The home maintains good links with service users’ relatives and ensures appropriate contact is arranged. Staff are committed to maintaining residents privacy and dignity and have worked hard to improve practices in the home so that residents can have more opportunities for personal development. This includes creating more opportunities for residents to plan and prepare their own meals. DS0000032045.V281850.R01.S.doc Version 5.1 Page 13 EVIDENCE: Since the previous inspection, additional staffing hours have been agreed. This has meant the home has been able to offer residents more choice of daytime activities. There was evidence on the service users’ files that were sampled that they had been consulted about what they would like to do. This had been recorded and included domestic tasks, gardening, visiting relatives, shopping, pursuing hobbies, cinema and skittles. On the day of the inspection 4 service users had stayed at the home to take part in the activities of their choice. For example, one service user went shopping in the morning for the ingredients to make their own lunch. Discussion with service users showed they were enjoying the opportunities the extra staffing hours had provided for them. The home’s statement of purpose says visitors are welcome at any time convenient to the service users. Visits can be made to bedrooms, lounges or the home will try to find a private room such as the office if necessary. Family contact arrangements are noted in individual care plans and service users are supported to visit their relatives. This was confirmed by one resident who told the inspector she was looking forward to visiting her relatives in the near future. Discussion with service users confirmed their privacy was respected in the home. Service users were observed to move freely around all the communal areas of the home and could choose whether to spend time in company or in the privacy of their rooms. There was a high level of interaction between service users and care staff and it was clear from observation of practice that positive relationships had been formed. Service users responsibilities for domestic tasks were clear and they have opportunities to take part in doing their own laundry, cleaning, shopping and managing their own money with support from staff as identified on individual care plans. Observed examples during the inspection included service users going shopping, preparing their own lunch and laying the tables for the evening meal. A recommendation was made at the previous inspection that further opportunities were provided for service users to shop, prepare and cook their own meals and the additional staffing hours have meant this is now possible. One of the senior officers told the inspector that the kitchen in one of the units was going to be re-fitted to make it safer for residents to use. This would also provide them with better opportunities to make their own meals. DS0000032045.V281850.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 20 The home has a good working knowledge of service users health needs but would benefit from making improvements to its system of recording information to ensure this is kept up-to-date and accurate. Improvements have been made to the way medication is administrated in the home ensuring service users medication needs are met. The current policy needs to be amended to accurately reflect practice in the home. EVIDENCE: Service users’ health needs were noted on the Establishments Task Lists and further information was available in their files. It was not always clear to the inspector which information was current. For example, one service user had a sheet detailing some physio exercises but there was nothing to indicate if this was ongoing or had been completed. All appointments are recorded and held on the home’s medication file. It is recommended that each services users current needs are more clearly identified and old information is filed away to avoid confusion. Discussion with the manager and members of staff showed that they had a good working knowledge of service users’ health needs. DS0000032045.V281850.R01.S.doc Version 5.1 Page 15 Medicines were stored securely in the home in a locked cupboard. The medication file was examined. The home uses Medicine Administration Records (MAR) charts, which are handwritten. These were found to be up-todate and accurate. The home now uses a code when medicines are taken away from the home such as when service users are at day centres. They are also recording the reasons why some medicines prescribed “when required” are used. All staff who give medication have completed a safe handling of medicines course. No service users are currently self-medicating and risk assessments were available to demonstrate why this was the case. A requirement was made by the specialist pharmacist inspector when the home was inspected in May 2005 that the medicines policy should be updated to include procedures for ordering medicines, receipt of medications, some aspects of administration, providing medicines when a service user is away from the home, verbal changes to medication and when there is a medication error. An up-to-date policy was not available on the day of this inspection and the inspector was told the policy was still being amended. DS0000032045.V281850.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed and met at the previous inspection. EVIDENCE: DS0000032045.V281850.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The home provides service users with a comfortable and homely environment, although some parts of the home would benefit from redecoration and some older items of furniture need replacing. The home was clean and hygienic with good procedures in place to protect service users from the spread of infection. EVIDENCE: A tour of the premises was carried out as part of the inspection. All communal areas of the home were viewed and a sample of service users’ bedrooms. The premises comprises of four different living units with between four and nine service users accommodated in a unit. Each unit has a small kitchen, dining room, lounge and bathroom and are made to look homely. The inspector noticed some of the décor was slightly tired looking with some tears in the wallpaper in places. Some of the furnishings were also worn and could do with replacing. The home continues to offer a respite service despite the fact the management team and staff consider the permanent residents would prefer not to share their accommodation with short term residents. The manager told the DS0000032045.V281850.R01.S.doc Version 5.1 Page 18 inspector this service had been substantially underused over the past year and that they were currently looking at future plans such as using one of the units to accommodate younger adults from the transition from children’s services. A recommendation was made at the previous inspection that the accommodation was made more suitable for a resident who uses a wheelchair. This was not assessed on this occasion so this recommendation is carried forward to the next inspection. The home was observed to be clean and hygienic. The inspector saw a policy and guidance for staff on infection control. Clear procedures were set out and further information was available about infectious diseases. Protective clothing and equipment was readily available in the home. Laundry facilities were appropriately sited and the facilities suitable for the needs of the service users. DS0000032045.V281850.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Substantial increases to staffing levels in the home have made a considerable difference to service users quality of life promoting their choice and opportunities for personal development. No new staff have been recruited in the home, so the inspector was unable to assess whether safe recruitment procedures were followed and this needs to be checked again at the next inspection. The home demonstrates a commitment to providing a well-qualified staff team and the training programme has been expanded to include courses designed to give staff an understanding of some of the specialist needs of service users and ensure their needs can be met. The home provides staff with good supervision and support ensuring they feel confident in carrying out their work. EVIDENCE: These key standards were assessed at the previous inspection. Requirements had been made concerning staff training and qualifications, staffing levels and recruitment procedures and these were reviewed at this inspection. DS0000032045.V281850.R01.S.doc Version 5.1 Page 20 The manager told the inspector that an additional 200 hours staffing had been provided per week, which means the home is now providing staffing in accordance with the hours recommended by the Department of Health’s calculation guidance. A sample of rotas was examined and this showed the extra hours were being used to provide additional staffing during the day to offer residents more choice of activities and promote their independence. There was written evidence that service users had been consulted about what they would like to do and staff had also had opportunities to discuss their views. The additional hours had only been provided for 2 weeks prior to the inspection, so the manager said that they were still reviewing the rotas to ensure that the additional hours were providing the maximum benefit for service users. A sample of three staff files was viewed as part of the inspection. No new staff had been employed since the previous inspection so the inspector was unable to check if recruitment procedures had been improved to ensure all new staff received CRB checks or at least a POVA first check before commencing employment in the home. There were still some gaps on staff files in obtaining proof of identity such as photographs and birth certificates and this will be assessed again at the next inspection to ensure recruitment procedures are complying with the regulatory requirements. All staff had contracts of employments setting out their terms and conditions and were subject to an initial probationary period. There was evidence in their files that the probationary period had been signed off, once this had been completed satisfactorily. There was also evidence of regular supervision sessions taking place with the notes of these recorded and held on staff files. A member of staff also confirmed that she had regular supervision sessions every 2 months. One of the senior officers is responsible for staff training and development in the home. A record is kept of all courses completed and this was seen by the inspector. Staff had undertaken a range of courses and there was evidence that this now included courses linked to the specialist needs of the residents such as autism, mental health issues, visual impairment and total communication. The senior officer told the inspector training was also being organised in group work to promote the homes additional staffing hours to support service users during the day. There are currently 6 care staff who have achieved NVQ level 2, which means the home is just under the target of having 50 of care staff qualified. However, a further 6 care staff commenced NVQ level 2 in September 05 demonstrating a commitment to ensuring staff are suitably qualified. The senior officer has now identified suitable LDAF induction and foundation courses and staff have been undertaking this training. DS0000032045.V281850.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 The home benefits from an experienced manager and senior team whose roles and responsibilities are clearly defined, which ensures that all aspects of running the home are well covered. The home encourages feedback about the quality of service from the residents and staff but needs to include this in a formal plan setting out aims and objectives for future service development. EVIDENCE: The manager, Dan Crone, has extensive experience of providing services for people with a learning disability and has managed Alexandra Road for a number of years. He holds the Certificate in Social Services and the Certificate in Personal Social Services Management. There was evidence that he was keeping his knowledge and skills up-to-date and recently undertaken training courses in personal development reviews, epilepsy, autism and an overview of induction standards and NVQs. DS0000032045.V281850.R01.S.doc Version 5.1 Page 22 There was evidence that feedback was encouraged in the home from service users and staff. For example, residents took part in a regular monthly meeting, they had also all been formally consulted about what they would like to do during the daytime, and an ideas board had been introduced for staff so they could make suggestions about practices in the home. CSCI receives regular monthly reports (Regulation 26) from the monitoring visits that are carried out by the registered provider, which provides further evidence about the quality of the service. The home needs to develop an annual plan based on the views of service users, staff and other interested parties to review the quality of its service and plan future service development. DS0000032045.V281850.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 2 X 3 X 2 X X X X DS0000032045.V281850.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? YES 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. Standard Regulation Requirement The Registered Manager must ensure a care plan is set up for all service users. Assessments and care plans must be regularly reviewed and kept up to date (Previous timescale of 01/01/05 not met.) The registered provided needs to up-date the medicines policy to include all the specified additions and ensure it accurately reflects current practice in the home. (Previous timescale of 30/06/05 not met.) The registered provider needs to achieve the target of at least 50 of care staff achieving a NVQ 2 qualification in care. (Previous timescale of 01/10/05 not met.) No person must start work in the care home until a satisfactory POVAFirst check has been received. Persons working in the home without a full CRB check must be supervised at all times by a designated person/s. DS0000032045.V281850.R01.S.doc Timescale for action 1. YA6 15 01/04/06 2 YA20 13 01/04/06 3. YA32 18 01/06/06 4. YA34 19 01/04/06 Version 5.1 Page 25 5. YA39 24 The registered provider must develop an annual development plan based upon seeking the views of service users and other interested parties, to ensure success in achieving the aims and objectives of the home. (Previous timescale of September 2003 not met) 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard YA6 Good Practice Recommendations It is recommended that information which is out-of-date on service users’ care plans is filed/archived so it is easy to identify which information currently applies to the service users’ care. It is recommended that risk assessments on individual files be reviewed to ensure they are appropriate and do not potentially limit service users’ choices. Service users should be enabled to have a holiday outside of the home. (This recommendation is brought forward from the inspection dated January 2004.) It is recommended that more information be recorded on service users health needs and how the home is to meet these needs. Filing out-of-date information would ensure that service users current needs are more easily identified. (This recommendation is brought forward from the inspection dated May 2005.) The home should be made more suitable for the service user who is a wheelchair user. (This recommendation was brought forward from the inspection dated May 2005 but was not assessed on this occasion.) It is recommended that the home’s short term care service is reviewed, as the communal areas cannot be separated from the living areas of the permanent residents and therefore, has a negative impact on the permanent residents in the home. It is recommended that consideration be given to redecorating some areas of the home and replacing items of worn furniture. DS0000032045.V281850.R01.S.doc Version 5.1 Page 26 1. 2. 3. YA9 YA14 4. YA19 5. YA24 6. YA24 7. YA24 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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