CARE HOME ADULTS 18-65
Kingsley Road (29,31,33) 29-31 Kingsley Road Chippenham Wiltshire SN14 0BF Lead Inspector
Tim Goadby Unannounced Inspection 12th & 21st October 2005 15:25 Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 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 Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 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. Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Kingsley Road (29,31,33) Address 29-31 Kingsley Road Chippenham Wiltshire SN14 0BF 01249 445763 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) Royal Mencap (Housing & Support Services) Ms Caroline Powney Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (4), Physical disability (4) of places Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16th May 2005 Brief Description of the Service: 29, 31 and 33 Kingsley Road provide care and accommodation for 8 adults, of either gender. Ages of the current group range from people in their 20s, to others in their 70s. The service is operated by Mencap, a national voluntary organisation in the learning disability field. Kingsley Road is run as one establishment. Numbers 29 and 33 each accommodate 2 people, who are able to be more independent. They do not need staff supervision at all times. But it can be accessed whenever necessary. The 4 people at number 31 need closer support. So this is where the staff team are based. This home includes the office, and sleep-in facility. The 3 houses are detached bungalows. They were purpose built in 1993, and are owned and maintained by Knightstone Housing Association. Kingsley Road is in a residential area of Chippenham, just 10 minutes walk from the centre. This market town offers a range of amenities. Rail and road links to the larger centres of Bath and Bristol are easily accessible. All service users have single bedrooms, with hand basins. There are no ensuite facilities. Each bungalow has a bathroom with a shower. There are also kitchens and a lounge. All the houses have their own area of garden. Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place in October 2005. There was an initial unannounced visit. A shorter return visit took place by appointment, to meet with the manager. This second occasion was used to check further records, and to confirm initial feedback. A total of 6 hours were spent in the service. The following inspection methods have been used in the production of this report: indirect observation; pre-inspection questionnaire, completed by the provider; sampling of records, with case tracking; discussions with service users, staff and management; survey of service users and relatives; tour of the premises. What the service does well: What has improved since the last inspection?
The service has made significant progress in resolving issues which were of concern at the previous inspection. 13 requirements were set following that visit, which took place in May 2005. A follow up visit in August 2005 found that the situation was much improved. All 13 requirements made at the last inspection were found to be met on this occasion. A number of those requirements related to the care of the home’s most recent admission. Steps are now in place to uphold their safety and welfare. All
Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 Page 6 required records have been put in place. There are appropriate guidelines for care and risk management. Suitable equipment has also been obtained, and staff have received the relevant training in its use. Excess furniture which was restricting available floor space in the service user’s bedroom has been removed. Review by the individual’s care manager has concluded that the person’s needs are now being met. Advice has been obtained to resolve an issue about the effective operation of fire doors, enhancing the protection of service users. A review of staffing levels has taken place, and a further meeting is to be held between Mencap and the CSCI to discuss the position. This work is being undertaken to ensure that the service can effectively meet all the assessed needs of its varied service user group. The service has completed a variation of its registration categories and conditions since the last inspection. This has resolved previous anomalies in the position. The relevant information now accurately reflects the actual and intended service user group. This means that care can be offered without any queries over the status of the establishment, providing greater security for service users. What they could do better:
A sampled service user’s file showed that identified mental health needs for that individual had not been reflected in clear care plan guidance. This placed the person at risk that these needs might not be supported effectively. The shower room in number 29 has presented problems for some time. The floor was re-laid incorrectly, so that water would not drain properly. A new tray had been installed during this inspection, but the floor surface needed refinishing to make the room available to service users again. Care plans for service users should be reviewed regarding their format and presentation. There is currently some duplication of information. The input of the individual could be more clearly shown, and the developing of meaningful goals for each person could flow from this. These recommendations are in line with work which Mencap is already proposing to undertake. Some medication practices could be reviewed, to enhance the protection of service users. Amendments made by the home’s staff to pre-printed medication administration charts should be clear, and properly crossreferenced to the appropriate medical advice. Approvals for non-prescription medicines should be obtained or updated where necessary. Some key records which are required to be available for inspection are only accessible if the manager is present. These include staff recruitment files, and
Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 Page 7 complaints records. The relevant requirements were met at this inspection, because the manager was available at the second visit. But systems should be implemented to ensure that evidence of required records can be produced in the manager’s absence. 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. Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 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 Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 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): 3 Service users have their needs and aspirations met by the home. EVIDENCE: The service has varied its registration categories and conditions since the previous inspection. They now more accurately reflect the service user group which is supported. This encompasses a range of adults with learning disability, including some who are aged over 65. Kingsley Road is also able to offer care to people with associated physical impairments. Up to 4 such places are available, these being the people living in number 31. Across its 3 bungalows, the service provides for people with a variety of needs. Those requiring the most input and supervision have continual access to this. Those able to live with a higher degree of independence can do so in numbers 29 and 33, whilst still having the safeguard of access to support at all times. The home’s newest service user has made good progress over the months since the last inspection. The home has taken various steps to ensure that all relevant support is in place to meet the individual’s needs. The positive benefits to the person are endorsed by the conclusion of their most recent review by their care manager, which states that the service is now meeting their needs well.
Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 Page 10 All 8 service users completed comment cards for this inspection. Responses were almost unanimously positive. Only 1 person raised any reservations about any aspects of the service provided. 6 relatives or friends of service users also completed comment cards, and all of these were satisfied with the overall care provided at Kingsley Road. Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 Service users have their abilities, needs and goals reflected in their individual plans. Service users are supported to take positive risks and access new opportunities, as part of an independent lifestyle. EVIDENCE: Sampled records showed that service users have individual plans in place, addressing relevant areas of need. These are supported by risk assessments and management strategies, where relevant. Care plans as currently presented could benefit from a number of improvements. Some information is duplicated across documents. This creates some confusion, and makes files less user friendly than they could be. Furthermore, the content of individual plans should develop. The input of the service user to their own care could be more clearly shown. This is especially so for goal setting. The examples seen were worded in very general terms, and were therefore not measurable.
Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 Page 12 The service intends to address such issues, via a thorough review of care planning over the coming months. The philosophy of ‘active support’ is to be adopted. This will include the development of goals based on the aspirations of service users. The newly appointed deputy manager is assisting with this process, having had experience of the approach in her previous setting. The manager had attended a relevant training session. Service users are encouraged to exercise independence wherever possible. This is particularly so for those living at numbers 29 and 33. It was evident that they are also supported to maintain personal safety. For instance, people showed appropriate care in establishing the inspector’s identity before granting admittance. Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15 & 16 Service users have the opportunity to maintain and develop skills. Service users are provided with a range of activities and opportunities, offering them full engagement with their local community. Service users are able to maintain and develop appropriate relationships with family and friends. Service users’ rights and responsibilities are upheld, balanced with appropriate steps to safeguard their welfare. EVIDENCE: Service users regularly access opportunities outside the home. This includes employment, education, occupation and leisure. Various daytime facilities are accessed, both in Chippenham and elsewhere.
Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 Page 14 On both days of this inspection visit people were due out on evening activities. Service users also spoke about the holidays they had been on over the summer. Records show that people are enabled to maintain regular contact with family and friends, where they have such relationships. All 6 relatives or friends who completed comment cards were happy with visiting arrangements, feeling that they are made welcome at any time, and can meet with service users in private. One person particularly commented that the service assists them with their visiting arrangements. Relatives also mostly felt that they are kept appropriately informed and consulted about the care of their family member. A couple of people indicated less satisfaction in this area, but no specific examples were given. At home, people are encouraged to participate in the various daily tasks. The level to which each individual does so varies, depending on their own abilities and strengths. There is more focus on enabling people to live independently at number 33, as the intention is that service users should move on from this house to less sheltered settings. Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users are supported to address their personal needs effectively. Appropriate guidance is not in place to ensure effective health care support for all service users, placing an individual’s welfare at risk. Service users are protected by the home’s policies and procedures for dealing with medicines. Further developments in practice could enhance this protection. EVIDENCE: Sampled service user records showed clear guidance on how to support people’s personal care needs. This includes instructions on any specific moving and handling techniques required to be used. The service supports people with a range of health needs. Records show that people are assisted to access all relevant sources of treatment and advice. Guidance is in place for the majority of identified issues. Waking night cover is provided in response to specific health needs of some service users at number 31, which require them to be checked at regular intervals. Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 Page 16 One deficit was identified, relating to mental health needs of one service user. Records contained information about the issues which had been noted as of concern. It was also evident that some relevant advice had been obtained on how to respond to these. But this had not been developed into clear guidance for staff, so it was not apparent whether the recommended approach was being applied. Failure to explicitly include the area in the main care plan also meant that it was not possible to see how it was being kept under review. None of the service users at Kingsley Road are self-medicating. So staff take on responsibility for this task. They receive in house training, and an assessment of competence, before they administer drugs to residents. There is also a system of double checking between the staff on duty at each medication round. Arrangements for the ordering and storage of medication were seen to be appropriate. Some improvements were recommended to do with recording. The service uses a system where medication administration charts are supplied pre-printed by the pharmacy, with regular drug orders. Any changes to these sheets are then made by hand. Examples were seen where such amendments, alterations or additions were not readily understandable. This was partly because they were not cross-referenced to the relevant reason for the change. A check of service user records was able to locate the appropriate medical advice for any alterations made. But this should be immediately clear from the administration chart itself. Evidence of GP approval for the giving of non-prescription medications – known as ‘homely remedies’ – was on file for some service users. But the 2 newest admissions did not have such records. And some other individuals had approvals dating from 1995, which should be updated. Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Service users are safeguarded by the home’s policies and procedures for complaints and protection. EVIDENCE: Mencap’s organisational complaints arrangements are appropriate. Information is clearly displayed within the service. It includes symbols and photographs, to help make it more accessible to service users. There is a full awareness of local procedures for the protection of vulnerable adults. When necessary, issues have been referred to this. The CSCI has also been notified of relevant matters. All Mencap staff attend training on abuse awareness and protection, as part of their core induction and foundation learning. All 8 service users indicated, via comment cards, that they feel safe at Kingsley Road, and know who to speak to if they are unhappy about anything. Of the 6 relatives or friends of service users who also completed comment cards, all but 1 indicated that they are aware of the complaints procedure. 2 people had made use of this in the past. Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 29 & 30 Service users live in a comfortable, clean and safe environment, suitable to their needs. Service users living at number 29 are disadvantaged by the temporary unavailability of shower facilities. Service users have suitable adaptations and equipment to promote their independence and quality of life. EVIDENCE: All 3 bungalows which comprise the Kingsley Road service constitute homes in their own right, offering all necessary living space. In addition to bedrooms, each building also has a kitchen, lounge, bathroom and toilet. Number 31 is suitable for people with a degree of physical impairment, including wheelchair users. However, available space, particularly in bedrooms, means the home could not support very highly dependent people. Bathrooms and toilets have various adaptations fitted to aid less mobile people, and wheelchair users. These include a fixed hoist for getting people in
Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 Page 19 and out of the bath, wall bars, and doors that can be opened automatically. One service user has been provided with a mattress raiser, which makes it easier for them to be supported to get in and out of bed. Numbers 29 and 33 enable people to live with more independence. They are connected to the central property by a call system. So service users can summon staff assistance whenever they need to. All 3 bungalows were seen to be clean and hygienic to a reasonable standard. They are also generally well maintained. Repairs and redecoration take place as necessary. Various areas have been addressed over recent months, and more work is planned. The shower room in number 29 was not in use, because of problems with water draining away properly. A floor covering which had been re-laid had been put down incorrectly, so that water leaked out into the corridor. By the second visit of this inspection, the floor had been taken up again to allow installation of a new shower tray. The covering therefore needed to be finished, so that the room could once more be used by the home’s occupants. Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Service users are supported by appropriately trained staff. Service users are protected by effective recruitment practices. Staff are supported and supervised effectively, enabling them to deliver a service that meets its users’ needs. EVIDENCE: Staff are on duty at all times when service users are at home. Cover is maintained at a minimum of 2 staff per shift. This includes 1 waking and 1 sleeping person overnight. 3 staff are on duty during daytimes, whenever possible. Both visits which made up this inspection process took place in the late afternoon and early evening. 3 staff were on duty on the first occasion; and 2 on the second. Staff are always present in number 31, where service users have the highest need levels. They give support to the other 2 homes as required. Following a period of staff turnover, which created some instability, the situation is now improving. A number of new staff have recently been recruited, and final checks were being made on other prospective starters. Once the latter are in post, the service will be at its full staff establishment for
Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 Page 21 the first time in some while. Continuing efforts are also being made to recruit more people for Mencap’s relief pool. This will help to ensure cover, in the event of other staff leaving in future. In line with a requirement of the last inspection, the service has undertaken a review of staffing levels. A meeting is now to be held between Mencap and the CSCI, to discuss the position further. The service has been developing support to people with physical needs, arising from their health and mobility. 2 to 1 support is required for some tasks with such service users; for instance, when assisting with personal care. Therefore, when there are only 2 staff on duty, the availability of support to other service users may be restricted. Staffing levels must be appropriate to meet all assessed needs of all service users. All 6 relatives or friends of service users who completed comment cards for this inspection were of the opinion that there are always sufficient staff on duty. Within the current Kingsley Road staff team, 4 people have achieved NVQ Level 2 in care, and another 2 people have Level 3. So the service is comfortably above the minimum 50 required for care staff qualified to this level. The manager and deputy are both training as NVQ assessors. Training records provide evidence of the service’s overall approach, and of the individual courses which each staff member has undertaken. There are clear expectations of all employees, from appointment onwards. Mencap has an organisational approach to induction and foundation training. The topics covered over the first weeks and months incorporate all mandatory requirements, and also key values and philosophies. All learning is documented, and is cross-referenced to relevant national standards for the social care workforce, and for people working in the learning disability field. Records showed that current staff are up to date on the various courses they need to attend, such as those on key health and safety topics. Each person’s training record also indicates when they will be due for refresher sessions. Supervision of staff takes place in planned meetings, which are held every 4 to 6 weeks. Each session lasts about an hour. Contracts are put in place, which govern the content and format of the meetings. The supervisor role is to be shared between the manager and the newly appointed deputy, once the latter has done relevant training. Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 The registered manager is suitably qualified, competent and experienced, so that service users benefit from a well run home. Quality assurance measures underpin service developments, and include actions based on the views of service users. Effective record keeping is maintained, upholding service users’ best interests. But the availability of some records for inspection is dependent upon the presence of the manager. Service users are protected from risk of fire by the safety systems in place. EVIDENCE: The registered manager for Kingsley Road is Caroline Powney. She is currently working towards the qualification levels that are now required, and is due to complete the relevant courses by September 2006. Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 Page 23 The service has a new deputy manager in post. The division of responsibilities between this role and that of the manager are being decided. The deputy role is seen as a career development opportunity, and the postholder will undertake training to the same level as required for a registered manager. Organisationally, there are clear structures within the regional Mencap team. Senior managers have set responsibilities in relation to the service. There appear to be good communication channels and support systems in place. This includes carrying out the monthly visits and reports on the conduct of the service that are required by care homes regulations. Mencap has an organisational approach to quality assurance. There are regional and area development plans, as well as service specific ones. The plan is set out under a number of topic headings, which ensure that all areas of service delivery are considered. There are topics which are particularly focused on service users. Areas for development are identified in various ways. These include internal audits; comments received from service users and others; and the findings of other agencies, such as the CSCI. Once an improvement task has been defined, it is made clear who is responsible for addressing this, and in what timescale. The plan also shows the way in which information about targets and progress is shared. Some key records which are required to be available for inspection are only accessible if the manager is present. These include staff recruitment files, and complaints records. The relevant requirements were met at this inspection, because the manager was available at the second visit. But systems should be implemented to ensure that evidence of required records can be produced in the manager’s absence. The fire log book was viewed. All required checks, practices and instruction relating to fire safety are recorded as being carried out, and up to date. A problem regarding the proper closure of all fire preventing doors appears to have been resolved. Advice has been obtained from the fire safety officer on the most effective way of addressing this problem. This has been communicated to Knightstone Housing Association, so any recurrence of the issue can be tackled appropriately. Kingsley Road (29,31,33) DS0000028374.V259701.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 3 X X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Kingsley Road (29,31,33) Score 3 2 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X 3 3 X DS0000028374.V259701.R01.S.doc Version 5.0 Page 25 No 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 YA19 Regulation 12(1); 13(1); 15 23(2)(j) Requirement Timescale for action 30/11/05 2 YA24 The persons registered must include in a service user’s written plan details of how all assessed health needs are to be met. The shower room in number 29 30/11/05 must be reinstated for the use of service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The format and presentation of care plans should be reviewed, to reduce duplication; promote the input of service users; and develop meaningful goal setting and evaluation. Handwritten amendments to pre-printed medication administration charts should be clear, and crossreferenced to the appropriate medical advice. ‘Homely remedies’ approvals should be obtained or updated where necessary. Systems should be implemented to ensure the availability of required records for inspection in the absence of the manager.
DS0000028374.V259701.R01.S.doc Version 5.0 Page 26 2 3 4 YA20 YA20 YA41 Kingsley Road (29,31,33) Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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