CARE HOME ADULTS 18-65
Brockleaze (27) 27 Brockleaze Neston Corsham Wiltshire SN13 9TJ Lead Inspector
Elaine Barber Key Unannounced Inspection 9th November 2006 13:40 Brockleaze (27) DS0000028367.V319699.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 Brockleaze (27) DS0000028367.V319699.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. Brockleaze (27) DS0000028367.V319699.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 Vacancy Care Home 3 Category(ies) of Learning disability (3), Physical disability (3) registration, with number of places Brockleaze (27) DS0000028367.V319699.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th October 2005 Brief Description of the Service: 27 Brocklease 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 Brocklease 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. Brockleaze (27) DS0000028367.V319699.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 9th November 2006 and a planned visit to the main office on 27th November 2006. During the visits information was gathered using: • • • • • • Observation Discussion with two people who lived in the home Discussion with two staff Discussion with the manager Telephone discussion with a social worker 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 prior to the inspection about the running of the home. One comment card was received from a staff member. A random inspection was conducted in April 2006. 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:
People’s individual needs were assessed so that their needs could be met. The two people who lived in the home had lived there several years and their needs had been assessed before moving in and as an ongoing process. One new person was considering moving in and assessment information was being obtained. Each person had a detailed individual support plan to address personal care needs. There were 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. 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. 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
Brockleaze (27) DS0000028367.V319699.R01.S.doc Version 5.2 Page 6 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 had detailed support plans so that they received support in ways they preferred and required. They had access to a range of health care professionals and their physical and emotional health needs were met. Medication was appropriately stored and people had their medication reviewed regularly to ensure that they had the right medication. There was a complaints procedure and a procedure about protecting vulnerable adults. There was information about the local vulnerable adults procedures and staff had received training about prevention of harm. People were protected by the home’s policies and practices about complaints and protection. The accommodation was spacious with a large lounge and dining room with a separate kitchen. Each person had their own bedroom, which was individually decorated. There was a laundry area with facilities to meet the laundry demands. The home was clean and tidy. There were plans to repair and redecorate the accommodation. People lived in a comfortable, clean environment. There was a minimum of one staff member on duty at any time during the day. At times 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 two people were 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. There were arrangements for supervision and appraisal so that people would benefit from well supported and supervised staff. An acting manager had been appointed to provide consistency for the people who lived in the home while there had been a vacancy for a manager. A new manager had since 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. What has improved since the last inspection?
Brockleaze (27) DS0000028367.V319699.R01.S.doc Version 5.2 Page 7 Each person had had a review of their care and objectives had been set for the forthcoming months. These objectives had been written into a plan for each person with the action to be taken to ensure that the objectives would be met. Following a recommendation at the previous inspection limitations were recorded in the care plans. For example the reasons why no lockable storage units were provided in the people’s bedrooms was recorded in their individual plans. This demonstrated that the reasons for not providing facilities had been thought through and were for the benefit of people. Following a requirement at the last inspection the manager had put together a plan of works and redecoration of the accommodation and arranged for contractors to make the improvements. Following a requirement at the last inspection the acting manager had conducted a survey of relatives’ and professionals’ views as part of the quality assurance process. What they could do better:
Improvements need to be made to the care planning system to ensure that people’s changing needs continue to be met. Care plans must be consistent within the home and be up to date and reviewed at least at six monthly intervals, with evidence kept. Each care plan should be dated so that staff can tell which information is up to date. Goals or objectives set at review meetings should be monitored consistently every two months. The range of activities and opportunities to access the community should be kept under review whilst staffing levels are reduced to ensure that people have as full participation in their local community as they are able. Changes need to be made to the medication practices to ensure that people are protected. When a member of staff administers medication they must sign the medication administration record in the appropriate place to demonstrate that the right medication has been given at the right time. 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. Any handwritten changes to the medication records should be clearly recorded with the dosage to ensure the correct amount of medication is given. The internal redecoration of the premises must continue in order to enhance the current standard of the accommodation so that people live in a pleasant environment. The manager must make an application to CSCI to become the registered manager to ensure consistency is maintained and that the people continue to benefit from a well run home.
Brockleaze (27) DS0000028367.V319699.R01.S.doc Version 5.2 Page 8 There must be a quality assurance system in use in the home to ensure that developments in the service are based on the views of people, their relatives and representatives. The quality assurance process must be finalised by producing a report on the findings of the recent survey and the quality of the service in the home and by sending the report to CSCI. 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. Brockleaze (27) DS0000028367.V319699.R01.S.doc Version 5.2 Page 9 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 Brockleaze (27) DS0000028367.V319699.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s individual needs were assessed so that their needs could be met. EVIDENCE: No new people had moved into the home since the last inspection. The two people who lived in the home had lived there several years and their needs had been assessed before moving in and as an ongoing process. One new person was considering moving in. The home had received care plans from the social work team and the team was going to do further assessments before introducing the person to the home. Brockleaze (27) DS0000028367.V319699.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 had their abilities, needs and goals reflected in their individual plans. However, some attention was needed to make the plans more consistent and to ensure they were reviewed. People made decisions about their lives with assistance as needed. People were supported to take risks and given opportunities for independence. EVIDENCE: The care records of the two people who lived in the home were checked. A requirement was made at the last inspection that care plans must be consistent within the home, be up to date and be reviewed at least at six monthly intervals with evidence kept. This had been partly addressed. Each person had a personal support programme and a daily routine. One person
Brockleaze (27) DS0000028367.V319699.R01.S.doc Version 5.2 Page 12 had had a review of their care in April 2006 and the other had a review in September 2006. 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 and the date was recorded. The plan of the other person for managing negative behaviours had been reviewed in October and the date was recorded. Their other support plans had not been reviewed. A recommendation was also made that goals or objectives set at review meetings should be included in the care plan so that they can be monitored and reviewed effectively. This had been addressed. Following the reviews of care objectives were agreed and written up into a plan with the action to be taken to achieve the objectives. There were monitoring sheets, which indicated that these objectives should be monitored every two months. One person had a record of monitoring the objectives every two months. However, the other person who had a review in April 2006 had only had their objectives monitored once since then. Limitations were recorded in the care plans. For example following a recommendation at the 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. People were observed choosing what to have for their evening meal. 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. Brockleaze (27) DS0000028367.V319699.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, 14, 15, 16, 17 Quality in this outcome area is generally 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. The range of activities and opportunities should be kept under review. People 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. People were offered a healthy diet and enjoyed their meals. Brockleaze (27) DS0000028367.V319699.R01.S.doc Version 5.2 Page 14 EVIDENCE: Each person had a programme of activities. One person had structured activities at a day service, which they attended four afternoons and a full day each week. The other person attended the service for three sessions a week. This 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. This person 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 reduced from two people on duty in the day to only one since there had been a vacancy in the home. Staff were trying not to let this impact on the people who still lived in the home and at times there were two staff on duty so that people could be supported individually with their activities. Comments from a social worker indicated that the reduced staffing levels might be limiting activities for people. Staff supported people to keep in contact with their family and friends. One person regularly saw a friend and recently had had a holiday in France with an ex member of staff. The other person visited their parents and their parents visited them once a month. Staff were also supporting this person to have contact with their sister. 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. 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. Brockleaze (27) DS0000028367.V319699.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 adequate. This judgement has been made using available evidence including a visit to this service. People received support in ways they preferred and required. People’s physical and emotional health needs were met. People were not wholly protected by the home’s policies and practices about medication. EVIDENCE: Each person had detailed support plans with information about how they wished to be supported. 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. 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
Brockleaze (27) DS0000028367.V319699.R01.S.doc Version 5.2 Page 16 regular dental and eye checks. Appointments with health care professionals were recorded. 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. Examination of the administration records showed that there were two errors. On one occasion medication had been given but the staff member who gave the medication had not signed the record. On another occasion the staff member had signed the record on the wrong day. However this was because when the medication records were printed the date column was not properly lined up and the sheets were misleading. Two recommendations were made at the last inspection about handwritten changes to the medication records. One stated that when changes are made two staff should sign to witness this. This had been addressed. A change had recently been made to a record and two staff had signed it. The second recommendation was about recording the dosage in numbers. However, the only change involved sachets of a homely remedy and did not include a dose or quantity. A social worker reported that a psychiatrist had changed the dosage of one person’s medication and this change had not been reflected in the medication sent from the pharmacist or the printed sheets. They were concerned because staff had not noticed this when checking the sheets and there was a possibility that the person could be given an overdose. They had brought this to the attention of the manager who was addressing this. Brockleaze (27) DS0000028367.V319699.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. However people would need the support of a representative or advocate to make a complaint. There had been no complaints since the last inspection. There was also a procedure about protection from abuse and information about the local multi-agency vulnerable 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. Brockleaze (27) DS0000028367.V319699.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, 30 Quality in this outcome area is adequate although steps were being taken to improve the quality of the environment. This judgement has been made using available evidence including a visit to this service. People lived in a comfortable, clean environment although improvements were needed to the décor and fabric of the building. 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 key inspection that improvements must be made to the environment. At the random inspection the previous manager had made a record identifying areas of the home that need work. She had decided that the vacant room was a priority and this was being enlarged, refurbished and redecorated. The kitchen had been completely refitted and redecorated and the standard of this room was greatly improved. A new doorframe had been installed but this needed sealing and painting. The front and back corridors were both in need of redecoration. A
Brockleaze (27) DS0000028367.V319699.R01.S.doc Version 5.2 Page 19 requirement was made that the manager must produce a plan of works to deal with areas, which needed repair and redecoration. This requirement had been addressed. At this inspection the new manager reported that she had produced a plan of works identifying the areas in the home, which needed repair and redecoration. Contractors had been engaged to carry out the works and were due to start within the next two weeks. 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 inspection. Brockleaze (27) DS0000028367.V319699.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 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. There were arrangements for supervision and appraisal so that people benefited from well supported and supervised staff. EVIDENCE: The rota showed that there was one member of staff on duty during the day and one member sleeping in at night. At times there were two members of staff so that both people who lived in the home could be supported with activities. There was occasional use of agency staff to cover the rota. Regular agency staff were used to provide consistency.
Brockleaze (27) DS0000028367.V319699.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. There was a recommendation at the last inspection that all staff should receive five paid training days a year. The records showed a lot of training and most staff had at least five days a year. One member of staff had a National Vocational Qualification (NVQ) at level two and two were working towards level two. There were five regular staff so when these people have completed the NVQ training this will mean the home has 60 of staff with a qualification. The standard about recruitment was met at the last main inspection. There had been one new member of staff since then. However they had transferred from another home within the organisation and all the appropriate checks were made when they were recruited to the other home. The home operated a system of peer supervision. Staff had supervision about every two months and an annual appraisal. There were team meetings once a month. The staff member who completed a comment card said that they had enough support to do their job well. Brockleaze (27) DS0000028367.V319699.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. Temporary management arrangements had been in place to ensure people continued to benefit from a well run home. People’s views underpinned all self-monitoring, review and development by the home although the findings and report about these views needs to be published. People’s health and safety were protected by the systems in place. Brockleaze (27) DS0000028367.V319699.R01.S.doc Version 5.2 Page 23 EVIDENCE: Since the last inspection a new home manager had been recruited. They were undergoing their induction period at the time of the inspection. They had a social work qualification and were about to register for the appropriate modules of the Registered Managers Award. They were about to apply to become the registered manager for the home. While there had been a vacancy for a manager a member of staff had been acting service manager responsible for managing the home. They were supporting the new manager during their induction to provide consistency. The acting service manager had recently started a quality assurance process. He had written to relatives, care managers and community nurses to obtain their views about the quality of care. He was waiting for the replies and then he planned to write a report about the responses and produce a development plan. 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. 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 regular checks of the fire safety measures and appropriate records were kept. Staff received quarterly fire instruction. Brockleaze (27) DS0000028367.V319699.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 X 2 3 3 X 4 x 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 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 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 2 X 2 X X 3 x Brockleaze (27) DS0000028367.V319699.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 YA6 Regulation 15 (2) (a) (b) (c) Requirement Care plans must be consistent within the home and be up to date and reviewed at least at six monthly intervals, with evidence kept. When a member of staff administers medication they must sign the mediation administration record in the appropriate place. The internal redecoration of the premises continues in order to enhance the current standard of the accommodation. (Carried forward from inspections dated 19th March 2003, 1st July 2004 and 25th November 2004, 14th October 2005 and 11th May 2006.) The manager must make an application to CSCI to become the registered manager. Timescale for action 31/01/07 2. YA20 13 (2) 09/11/06 3. YA24 23(2) (b) 31/12/06 4. YA37 8-(1) 31/01/07 Brockleaze (27) DS0000028367.V319699.R01.S.doc Version 5.2 Page 26 5. YA39 24 There must be a quality 31/01/07 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 by the date shown. (Carried forward from previous inspections 25th November 2004, 14th October 2005 and 11th May 2006.) 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 YA14 YA20 Good Practice Recommendations 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. The range of activities and opportunities to access the community should be kept under review whilst staffing levels are reduced. 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. Any handwritten changes to the medication records should be clearly recorded using numbers for the dosage for the benefit of agency staff. 5. YA20 Brockleaze (27) DS0000028367.V319699.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
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