CARE HOME ADULTS 18-65
Brockleaze (27) 27 Brockleaze Neston Corsham Wiltshire SN13 9TJ Lead Inspector
Elaine Barber Key Unannounced Inspection 12th September 2007 11:50 DS0000028367.V344610.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 DS0000028367.V344610.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. DS0000028367.V344610.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Brockleaze (27) Address 27 Brockleaze Neston Corsham Wiltshire SN13 9TJ 01225 811902 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.unitedresponse.org.uk United Response Jill Patricia Cooper Care Home 3 Category(ies) of Learning disability (3), Physical disability (3) registration, with number of places DS0000028367.V344610.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th November 2006 Brief Description of the Service: 27 Brockleaze is a detached bungalow in the village of Neston, close to the towns of Chippenham and Corsham. The home is in a rural location. There is a pub fairly close by and a shop a short drive away. This is one of a number of homes run by an organisation called United Response. 27 Brockleaze provides care and accommodation for three people, aged between 18 - 65 years, who have a learning disability. Each person has their own single bedroom. There are no hand washbasins and no lockable units in the bedrooms. There are two bathrooms. There is a lounge, a small dining room, a kitchen, a separate utility room and a large garden with parking for several cars. One member of staff sleeps in every night and there are one or two staff on duty each day. The fees range between £ 1321.23 and £1437.36. DS0000028367.V344610.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home on 12th September 2007. During the visit information was gathered using: • • • • • Observation Speaking to two people who lived in the home Discussion with two staff Discussion with the manager Reading records including care records. Other information and feedback about the home has been received and taken into account as part of this inspection: • • • The manager provided information before the inspection about the running of the home. One comment card was received from a doctor. One comment card was received from a relative. The judgements contained in this report have been made from all this evidence gathered during the inspection, including the three inspection visits. What the service does well:
There was a statement of purpose and service user guide, which needed to be reviewed. A new manager was in post and the guide needed to include information about them. People therefore had most of the information they needed to make an informed choice about whether the home would meet their needs. Each person’s needs were assessed so that their needs could be met. People had the opportunity to visit and try out the home before they moved in. One person had recently moved in and had made several visits to the home to meet the people who lived there and the staff. Each person had a detailed individual support plan to address personal care needs. There were also individual support plans to address health care needs and any assistance they needed to manage their behaviour. People had their abilities, needs and goals reflected in their individual plans to ensure that their needs would be met. However, some attention was needed to make the plans more consistent and to ensure they were reviewed and up to date. People were offered choices and people made decisions about their lives with assistance as needed. There were a range of individual risk assessments and people were supported to take risks and given opportunities for independence. People had activities and opportunities to access to their local community. DS0000028367.V344610.R01.S.doc Version 5.2 Page 6 People attended a resource centre and used community facilities such as the shops and the pub. People were able to maintain and develop appropriate relationships with family and friends. One person had regular contact with a friend whilst another regularly visited and had visits from their family. People’s rights were respected and their responsibilities were recognised in their daily lives. There was a varied menu, which reflected people’s choices and people were involved in shopping and meal preparation. People were offered a healthy diet and enjoyed their meals. People received support in ways they preferred and required so that their physical and emotional health needs were met. Records were made about how people liked to be supported. They were all registered with a GP and saw a range of other health professionals when needed. Medication was appropriately stored and was generally well recorded. This ensured that people were protected by the home’s policies and practices about medication. There was a complaints procedure and complaints and concerns were listed to and acted upon. A relative said that concerns were resolved before the need to make a formal complaint. There was a procedure for safeguarding adults from abuse and staff had received training about prevention from harm. People were protected by the home’s policies and practices about complaints and protection. Most of the accommodation was clean, hygienic and suited to people’s needs. There was a large lounge, which had recently been repainted. There were three large single bedrooms, which were individually decorated and furnished. There were sufficient bathrooms and toilets. The staff were planning changes to the bathroom with the advice of an occupational therapist to ensure that it would meet people’s needs. There was one staff member on duty during the early morning and late evening. During the day and early evening there were two members of staff to support people with their activities and appointments. There was a training programme and new staff had learning disability award framework induction and foundation training. One member of staff had a National Vocational Qualification (NVQ) at Level two and another member of staff was working towards level two. There was a range of training for staff. People were supported by an effective staff team, who were appropriately trained and competent to meet their needs. People were protected by the home’s recruitment practices. New staff had an interview, two written references were obtained and Criminal Records Bureau and Protection of Vulnerable Adults checks were obtained before new staff started work. A new manager had been appointed who was suitably qualified, and experienced so that people would benefit from a well run home. There was a range of health and safety measures and staff had received appropriate training. People’s health and safety were protected by the systems in place.
DS0000028367.V344610.R01.S.doc Version 5.2 Page 7 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.
DS0000028367.V344610.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 DS0000028367.V344610.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): 1, 2, 4, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People had most of the information that they needed to make an informed choice about whether the home would meet their needs. People’s needs were assessed so that their needs could be met. People had the opportunity to visit and try out the home before they moved in. Some people or their representatives did not have a statement of their terms and conditions or a contract with the home. EVIDENCE: There was a statement of purpose and service user guide, which needed to be reviewed. A new manager was in post and the guide needed to include information about them. One new person had recently moved into the home. The manager said that they were not in post when they moved in so they were not able to confirm whether the person and their family were given a copy of the service user guide. DS0000028367.V344610.R01.S.doc Version 5.2 Page 10 Staff provided information about when the person moved into the home. They stated that the person first came to Brockleaze to visit with their family and care manager. After this they had several more day time visits in order to meet the other two people who lived at Brockleaze. Once the person and family had decided they wanted to live at Brockleaze the staff discussed this with the other two people. After this had happened the staff from Brockleaze spent some time with the person in their present home in order to build relationships. The person spent one overnight stay at Brockleaze before they moved in. A relative said in their comment card that great care was taken about introducing a new person into the home. The two people who had lived at Brockleaze for several years had their needs assessed when they moved in. They had also had ongoing assessment by staff and reassessments and reviews of their needs by care managers. The person who had recently moved in had an assessment by a care manager before they moved in. They had moved from a home managed by United Response and they also had assessment information from their previous home. The person who had recently moved in had a service user charter which set out their terms and conditions and fees for their previous home. They needed a service user charter which set out their terms and conditions and fees for 27, Brockleaze. One of the other people had a service user charter signed by a representative of United Response but not by the person or their representative. The manager said that each person also had a social services contract. However, these were held in the head office and were not held by the people concerned and were not available for inspection. DS0000028367.V344610.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. People’s abilities, needs and goals were reflected in their individual plans but these were not up to date. People made decisions about their lives with assistance as needed. People were supported to take risks and given opportunities for independence. EVIDENCE: A requirement was made at the last inspection that care plans must be consistent within the home and be up to date and reviewed at least at six monthly intervals, with evidence kept. A recommendation was made that each care plan should be dated so that staff can tell which information is up to date. These had not been addressed. DS0000028367.V344610.R01.S.doc Version 5.2 Page 12 The care plans of two people who had lived in the home for several years were read. They had detailed support plans for different aspects of their care for example travelling in the car, communication, eating and drinking, medication, managing behaviour, managing seizures and spending time in the garden. The care plans for the two people were not consistent with each other and had different formats. The support plans were not always dated so it was hard to tell which information was current. The plans for one person had been reviewed regularly approximately once a year and the date was recorded. The plan of the other person for managing negative behaviours had been reviewed in October 2006 and the date was recorded. Their other support plans had not been reviewed. However, they had had a review of their care in December 2006. One person who had recently moved into 27, Brockleaze had transferred from another United Response service. They had care planning information from their previous home. However this needed to be updated and made consistent with the other care plans at Brockleaze. Their care plans were not dated Another recommendation was made at the last inspection that goals or objectives set at review meetings should be monitored consistently every two months. The two people who had been in the home for several years had objectives set following their reviews. However these were not written up into a plan so that they could be monitored. The third person had not had a recent review. Limitations were recorded in the care plans. For example following a recommendation at a previous inspection the reasons why no lockable storage units were provided in the people’s bedrooms were recorded in their individual plans. Examples of when people made choices were also recorded in their daily records for example one person chose the décor for their bedroom. People had support from staff to manage their finances. They had a choice of activities in the evenings and when they did not have structured activities. There was a range of individual risk assessments. These focused on promoting independence and included the benefits for each person of participating in an activity, which may pose a risk. The assessments included the action that was to be taken to minimise risks, they were dated and reviewed annually. Several had been reviewed within the last month. DS0000028367.V344610.R01.S.doc Version 5.2 Page 13 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, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People had activities and opportunities to access their local community. They were able to maintain and develop appropriate relationships with family and friends. People’s rights were respected and their responsibilities were recognised in their daily lives. They were offered a healthy diet and enjoyed their meals. EVIDENCE: A recommendation was made at the last inspection that the range of activities and opportunities to access the community should be kept under review whilst staffing levels are reduced. This had been addressed and staffing levels had increased. DS0000028367.V344610.R01.S.doc Version 5.2 Page 14 Each person had a programme of activities. Two people had structured activities at a day service. One person also had activities at home including cleaning, help with the laundry, household chores, going for walks and going shopping for food and personal items. They also enjoyed going to the pub. Each person was supported individually with activities by staff. At home they did puzzles, watched television and videos and listened to music. The staffing levels had been increased to two since the third person had moved into the home. This meant that people could access more activities. Staff supported people to keep in contact with their family and friends. One person regularly saw a friend and recently had had a holiday with their friend. Another person visited their parents and their parents visited them once a month. They had a sofa in their room so that they could entertain their parents in the privacy of their room. Staff were also supporting this person to have contact with their sister. The third person kept in contact with their mother. The daily routines were flexible and fitted round the people’s needs and preferences. People could choose to spend their time in the communal areas or in their own rooms. On the day of inspection one person was spending time in the garden and another was in the lounge. Staff entered people’s rooms only with permission. People did not have locks on their bedroom doors but the reasons for this were recorded in their care plans. There was a varied menu, which showed that a good mixed diet was being provided. Staff said that they chose the menus based on their knowledge of people’s likes and dislikes. People were also involved in the shopping and chose items of food in the supermarket. People were supported with meal preparation and making drinks. There were records in the personal diaries about the people enjoying their meals and choosing what to have for meals. A member of staff said that people chose their meals on a daily basis. Staff offered them choice from a small selection bearing in mind what they had eaten recently. This ensured that there was a balance between having choice and ensuring people had a healthy diet. DS0000028367.V344610.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People received support in ways they preferred and required so that their physical and emotional health needs were met. People were generally protected by the home’s policies and practices about medication. EVIDENCE: There was information in each person’s support plan about how they wished to be supported. People were encouaged to choose which staff they wanted to provide support for them. Personal care was provided in the privacy of the bedroom or bathroom. People had individual clothes and hairstyles. There was a keyworker system and additional specialist support was provided. Healthcare needs were assesed and recoqnised. There were policies and guidelines about intimate support. Each person was registered with a GP. They also had access to other health care professionals such as a psychiatrist and community nurse. People had regular dental and eye checks. DS0000028367.V344610.R01.S.doc Version 5.2 Page 16 Appointments with health care professionals were recorded. The GP who completed a comment card said that they were able to see their patients, from the home, in private. They said that that staff demonstrated a clear understanding about people’s care needs. They also said that when they gave specialist advice this was incorporated into the support plans. The relative who completed a comment card said that they were always told of any appointments their relative had with a doctor or the hospital. They also said that staff always gave the support and care to their relative that they expected. They stated that one of the things the home did well was looking after their relative’s health and medical needs. Each person had an assesment that identified the level of support they required for taking medication and the need for staff to take on this task. A record was made of each person’s medication in their personal notes. Medication was reviewed by a GP or consultant. Medication was stored appropriately in a metal cabinet. A monitored dosage system was used and a record was kept of medication received into the home, administered, returned to the pharmacist and destroyed. A record of medication received was made on the administration record sheet. There was a separate record of medication returned to the pharmacist and a weekly stock control sheet. A requirement was made at the last inspection that when a member of staff administers medication they must sign the medication administration record in the appropriate place. This requirement had been addressed. The medication administration record sheets were checked and were well recorded. A recommendation was also made that when medication is received from the pharmacist the medication and the administration records should be checked to ensure that it is the correct medication as prescribed by the doctor and the medication records are accurate. This had been addressed. A further recommendation was made that any handwritten changes to the medication records should be clearly recorded using numbers for the dosage for the benefit of agency staff. This had also been addressed. However, some of the handwritten changes had not been checked and signed by two members of staff to ensure they were correct and they were not dated to show what period they referred to. DS0000028367.V344610.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were protected by the home’s policies and practices about complaints and protection EVIDENCE: There was a complaints procedure. All the people who were supported were given a copy of the United Response complaints procedure, in an apporopiate format. However people would need the support of a representative or advocate to make a complaint. A copy of the complaints procedure was seen in each person’s file. There had been no complaints since the last inspection. Relatives who completed a comment card said that they knew how to make a complaint and any concerns they raised have been dealt with without the need to make a formal complaint. They also said that the care service has responded appropriately if they have raised concerns. There was also a procedure about protection from abuse and information about the local multi-agency safeguarding adults procedure. There had been no allegations of abuse. The training records showed that care staff received training about prevention of harm. Staff supported people to manage their money and appropriate records were kept. A relative commented that staff helped their relative to budget and spend wisely so that they were always well dressed and could afford outings.
DS0000028367.V344610.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, 27, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most of the accommodation was clean, hygienic, well decorated and furnished and suited to people’s needs. EVIDENCE: There was a large lounge, a separate dining room, kitchen and three single bedrooms. There were appropriate bathroom and toilet facilities. A requirement was made at the last inspection that the internal redecoration of the premises continues in order to enhance the current standard of the accommodation. This had been addressed. The lounge and corridor by the bedrooms had been repainted. The accommodation looked very homely. New curtains had been purchased and were due to be hung. DS0000028367.V344610.R01.S.doc Version 5.2 Page 19 There were three large single bedrooms, which were individually decorated and furnished. One of the rooms had recently been enlarged and was redecorated and re-carpeted. There was a bathroom and a shower room. The bathroom was in need of some attention. There was mould on the ceiling, some of the paint was peeling and the bath panel was damaged. The manager reported that they were assessing the needs of the person who had recently moved in and were seeking the advice of an occupational therapist. They planned to install a new bathroom, which would meet the person’s needs and have better ventilation. There was a utility area next to the kitchen with a washing machine and tumble drier. These were sufficient for people’s laundry needs. The home was clean and tidy on the day of the inspection. DS0000028367.V344610.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported by an effective staff team, who were appropriately trained and competent to meet their needs. People were protected by the home’s recruitment practices EVIDENCE: The rota showed that there was one member of staff on duty in the early morning and late evening and one member of staff sleeping in at night. During the day and early evening there were two members of staff on duty to help with activities. On the day of the inspection the second member of staff went off duty early because there were only two people at home. The third person who lived in the home was away on holiday. There were three regular members of staff, two full time and one part time. The staffing had been increased since the third person had moved into the home. The additional hours were being covered by regular agency staff and relief staff to provide consistency. One of the agency staff had recently been recruited as a permanent staff member.
DS0000028367.V344610.R01.S.doc Version 5.2 Page 21 There was a training plan, which showed that staff were provided with a range of training. The training records showed that staff received training about first aid, food hygiene, manual handling, health and safety, challenging behaviour, medication, epilepsy, prevention of harm and autism. New staff had Learning Disability Award Framework (LDAF) induction and foundation training. Since the last inspection there had been updates about training in challenging behaviour, the way we work, prevention from harm, loss and bereavement and manual handling. One member of staff had a National Vocational Qualification (NVQ) at level two and one was working towards level two. The standard about recruitment was met at the last main inspection. New staff had an interview, two written references were obtained and Criminal Records Bureau and Protection of Vulnerable Adults checks were obtained before new staff started work. There had been one new member of staff recruited since then. However their employment checks had not been completed and they were still working through the agency. DS0000028367.V344610.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, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was no registered manager although a new manager had been appointed who was suitably qualified, competent and experienced so that people would benefit from a well run home. There was no review of the quality of the service based on people’s views. People’s health and safety were generally protected by the systems in place. EVIDENCE: A requirement was made at the last inspection that the manager must make an application to CSCI to become the registered manager. This manager had not made a full application and had since left. DS0000028367.V344610.R01.S.doc Version 5.2 Page 23 A new home manager had been appointed. They had transferred from another home where they had been the registered manager. They were about to apply to become the registered manager for this home. Another requirement was made that there must be a quality assurance system in use in the home. A report on the findings of the recent survey and the quality of the service in the home must be sent to CSCI. The manager reported that there had been no further developments in quality assurance and questionnaires needed to be sent out. There was a health and safety policy and staff received training about health and safety. Records of health and safety checks were made in a health and safety folder. These included records of water temperatures, fridge and freezer temperatures, vehicle checks, medication stock checks, monthly checks of the first aid kits and monthly hazard inspections. Thermostatic valves on taps and the boiler were serviced. There had been some problems with the boiler, which meant that, at times, there was no hot water. The boiler had been repaired the previous week. The electrical wiring and portable appliances were checked. There was information about Control of Substances that are Hazardous to Health. The Environmental Health Officer had visited in September 2006 and there were no outstanding issues about food safety or health and safety. There were checks of the fire safety measures and appropriate records were kept. Some of the checks for July and August had not taken place and the manager said that she would ensure all future checks took place at the right time. Staff received quarterly fire instruction. DS0000028367.V344610.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 5 2 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 3 25 3 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X 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 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 1 X X 3 X DS0000028367.V344610.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5 (1) b and c Requirement Each person must have a statement of their terms and conditions or contract with the home. Care plans must be consistent within the home and be up to date and reviewed at least at six monthly intervals, with evidence kept. Timescale for action 31/12/07 2. YA6 15 (2) (a) (b) (c) 31/12/07 3. YA39 24 31/01/08 There must be a quality assurance system in use in the home. A report on the findings of the recent survey and the quality of the service in the home must be sent to CSCI. (Carried forward from previous inspections 25th November 2004, 14th October 2005 11th May 2006 and 9th November 2006.) The manager must make an application to CSCI to become the registered manager. 31/10/07 5. YA37 8-(1) DS0000028367.V344610.R01.S.doc Version 5.2 Page 26 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 YA6 YA6 YA6 YA20 Good Practice Recommendations It would be good practice following a review to write a plan with the action to be taken to achieve each objective set. Goals or objectives set at review meetings should be monitored consistently every two months. Each care plan should be dated so that staff can tell which information is up to date. Any handwritten changes to the medication records should be checked and signed by two members of staff. They should also be dated so that they can be cross-referenced with advice recorded in the records of GP visits. DS0000028367.V344610.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 DS0000028367.V344610.R01.S.doc Version 5.2 Page 28 - 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!
