Inspection on 24/08/07 for 30 Broad Lane

This inspection was carried out on 24th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

30 Broad Lane 19/08/08

30 Broad Lane 06/06/06

30 Broad Lane 16/01/06

30 Broad Lane 25/07/05

30 Broad Lane 21/02/05

30 Broad Lane 17/05/04

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

CARE HOME ADULTS 18-65 30 Broad Lane Upper Bucklebury Nr. Reading Berkshire RG7 6QJ Lead Inspector Jill Chapman Unannounced Inspection 24th August 2007 10:30 30 Broad Lane DS0000011147.V344530.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 30 Broad Lane DS0000011147.V344530.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. 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 30 Broad Lane Address Upper Bucklebury Nr. Reading Berkshire RG7 6QJ 01635 871191 01635 871191 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) londonroad@tiscali.co.uk Milbury Care Services Ltd ***Post Vacant*** Care Home 6 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4), Physical disability (2), of places Physical disability over 65 years of age (2) 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2006 Brief Description of the Service: This service provides care and accommodation to five residents, of both genders aged between 18 and 65 with learning and some physical disabilities. The Milbury group operates the home. The service aims to enable service users to live a fulfilled life underpinned by The Five Accomplishments of Ordinary Living (John O’Briens). The home is a two storey detached house in situated in Upper Bucklebury. The house is located on a main road but is set back from this; it is close to local amenities. The home has a good-sized rear garden and ample parking to the front of the property. The unit manager commenced in post in July 2005. The current fees for the home range from £1035.63 to £1820.27 per week. 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 10:30am and was in the service for four and a half hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector toured the premises and spoke with the manager and two staff. All five service users were present at various times during the visit and some observation of practice was observed. Service users in the home have communication difficulties but the inspector was able to see them make their needs known to staff on duty. Some of them completed surveys with staff support and their views are represented in this report. What the service does well: The home only accommodates service users whose needs it can meet and would be able to accommodate service users who have equality and diversity needs. Service users surveyed (with staff support) said they received enough information about the home before moving in. Service users know their assessed needs and preferences are recorded in their plan. They are supported to make decisions and to take responsible risks. The home would be able to support service users with diverse religious or cultural needs. Service users will benefit from good community access, activities and holidays of their choice. Service users can make choices about what they do with their time and there is opportunity for daily outings. The manager and staff advocate on service users behalf whether at home or when they encounter difficulties when accessing the community. They are supported to keep in contact with family and friends. They have a healthy diet, which they help choose. 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 6 Service users receive personal care in the way they prefer. Regular health checks and support from staff to take their medication helps keep service users well. Service users said that staff treat them well and listen to them. A relative said that the home is good at supporting the service users. Service users and their relatives know that complaints will be dealt with. Some improvement is needed in the recording of complaints investigated by head office. Staff are trained to know how to protect service users from potential abuse and there are systems in place to protect their property and finances. Service users benefit from a comfortable and well cared for home. Cleanliness and hygiene in the home have improved as a result of staff training. Service users benefit from enough staff who are trained to meet their needs. Staff were positive about the developments in the way they work and can see the benefits for service users. A robust recruitment procedure is in place to make sure that staff are suitable to work with service users. Staff receive supervision and support in their work with service users. The home is well managed and there are systems in place to seek the views of service users and others to develop the service. The manager has successfully promoted a more service user focussed culture in the home. Health and safety systems are kept up to date to keep service users safe. What has improved since the last inspection? Care records and risk assessments have been further developed. A pictorial version of the complaints procedure has been made available to service users. The laundry has been extended and the floors replaced and walls have been made good. The manager said that the laundry is now more accessible to service users so that they can help with their washing. Since the last inspection all staff have received infection control training and the manager said this has had a positive impact on domestic routines. Since the last inspection staff shift patterns have been reviewed to better meet service users needs. Rotas are planned so that there is a skill mix on each shift. There has been significant progress in staff development and user focussed care practice since the last inspection. 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 7 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. 30 Broad Lane DS0000011147.V344530.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 30 Broad Lane DS0000011147.V344530.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home only accommodates service users whose needs it can meet and could accommodate service users who have equality and diversity needs. Service users surveyed (with staff support) said they received enough information about the home before moving in. EVIDENCE: There have been no new service users since the last inspection. The home currently has five service users who have all lived in the home for some time. Milbury has an assessment procedure, which the manager would use to make sure the home could meet the needs of any new service user. There was evidence from service users files that regular reviews are carried out to make sure the home is meeting service users needs. The manager confirmed that the assessment would include looking at whether potential service users had any equality or diversity needs. Service users surveyed (with staff support) said they received enough information about the home before moving in. 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know their assessed needs and preferences are recorded in their plan. They are supported to make decisions and to take responsible risks. The home would be able to support service users with diverse religious or cultural needs. EVIDENCE: Service users files show that there are up to date support plans in place to help staff meet service users needs. The plans have step-by-step instructions to show staff how to achieve each task according to each service users needs or preference. Daily notes sampled showed that support plans are carried out and plans had been reviewed. Key workers have been allocated and person centred plans are being developed. Staff spoken to were clear about their key worker role and responsibilities. The home does not accommodate any service users with diverse religious or cultural needs at present but the manager was aware of how to meet these and of local cultural resources if needed in the future. The staff team has a mixed culture and this would be an added resource if needed. 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 11 There is evidence from support plans sampled that service users choice is respected and a list of their likes and dislikes are kept on file. Any need to override choice for safety reasons is recorded and written consent is sought from relatives or advocates. There has been further development of risk assessments as recommended at the last inspection. Risk assessments have been reviewed and those seen gave detailed information about what actions staff have to take to reduce risks. 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 & 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users benefit from good community access, activities and holidays of their choice. Service users can make choices about what they do with their time and there is opportunity for daily outings. The manager and staff advocate for service users at the home and when they encounter difficulties when accessing the community. They are supported to keep in contact with family and friends. They have a healthy diet, which they help choose. EVIDENCE: No service users are able to take up employment opportunities but staff support them to participate in appropriate structured activities in the local community. As recommended from the last inspection, the home has further developed opportunities for activities and access to the local community. Some service users go swimming, to a sensory room, trampolining and the Gateway Club. A Musical entertainer visits the home every fortnight. 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 13 Investigations are taking place to look for a suitable Ice Skating venue. Some service users have outreach activities provided by the local authority. Service users surveyed confirmed they choose what to do during the day and evening. One said that she goes out in the car or for a walk every day, does her own shopping and chooses what to wear. The home is well situated for spontaneous countryside walks and new wheelchairs have been delivered. There is a house car and some service users are supported to use public transport. Some service users attend the village church each Sunday and a monthly religious group for people with a learning disability. In discussion with the manager and staff it was clear that they advocate on service users behalf whether at home or in the local community. Staff gave several examples of needing to challenge discriminatory reactions from members of the public. Service users are supported to enjoy a holiday away from the home; some have already been to Centre Parcs at Bath and to Hayling Island. Plans for a holiday to France are being explored for another service user and another would prefer day trips to the seaside. Staff support service users to keep in touch with their families and friends via visits. Details of next of kin and important family members are kept on their files. A relative confirmed that the manager keeps in touch should any issue need discussion. The arrangements for food are being developed to involve service users more. As recommended at the last inspection a new menu plan has been implemented, this includes the use of a pictorial menu to help service users see what is on offer. Menus are planned taking into account service users preferences and a record of food eaten is kept. Food stocks were good and there was plenty of fresh fruit and salad. Staff encourage service users to help with the shopping. A lunchtime meal was observed, there was good staff support for service users who need physical or prompting help at mealtimes. The layout of the dining area enables choice, privacy and separation at mealtimes. 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal care in the way they prefer. Regular health checks and support from staff to take their medication helps keep service users well. EVIDENCE: Personal care plans give clear information about how service users like to be helped. For example there are detailed bathing and eating plans. Other guidelines, such as Communication Passports and Objects of Reference, help staff know how to communicate with service users. Up to date guidelines are in place to help staff deal with behaviour that challenges the service. It was observed that staff coped well with behaviour that could have compromised a service user’s privacy and dignity. The situation was handled in a way that protected the service user’s privacy and prevented other service users being affected. A relative said that the home is good at supporting the service users. 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 15 A previous requirement that health care records are developed ensuring that necessary health checks are kept up to date, has been met. Records of appointments with health professionals are kept to ensure continuity and monitoring tools such as weight charts are kept. It was seen that the home has a suitable procedure for the safe storage and administration of service users medication. Records show that staff are trained to give medication and their competency is re-assessed every six months. There is information for staff on medication taken by service users and a record of any medication that service users are allergic to. A stock control system is in place to check that stocks are accurate. It is good practice that medication is checked at each staff handover to make sure there are no errors. 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives know that complaints will be dealt with. Some improvement is needed in the recording of complaints investigated by head office. Staff are trained to know how to protect service users from potential abuse and there are systems in place to protect their property and finances. EVIDENCE: Service users and their families receive copies of the complaints procedure and this is evidenced on service users files. Since the last inspection a pictorial version has been introduced to make it more accessible to service users and copies are displayed in service users bedrooms. Surveys confirmed that staff know how to interpret service users non-verbal dissatisfaction and deal with their concerns. The Commission has not received any information since the last inspection from service users or their relatives about complaints about the service. The home has received two complaints from a neighbour and these have been dealt with by head office. More information needs to be recorded on the home’s complaints record to show that these have been dealt with according to the policy and outcomes recorded. There is good evidence on staff files to show that staff have received Protection of Vulnerable Adults training and have read the Milbury POVA policy. Staff also are given training on the Whistle Blowing Policy and Non Violent 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 17 Crisis Intervention. There is an accessible version of the POVA policy to help service users protect themselves. The manager is aware of the local interagency procedures and the contact person for reporting potential abuse. The Commission has not received any information about safeguarding referrals regarding the service users and none have been made by the home. The manager has received POVA training but it is recommended that the manager also undertake POVA level 2 training. It was seen that there are systems in place to protect service users property and finances. There is an inventory kept of their property and a system for dealing with their money, which is checked at each handover. 30 Broad Lane DS0000011147.V344530.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 good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a comfortable and well cared for home. Cleanliness and hygiene in the home has improved as a result of staff training. EVIDENCE: The premises were seen and are generally in a good state of decoration and repair. Some bathroom and shower room flooring is in need of repair or replacement. The garden is secure and well kept and new garden furniture has been purchased. There is no designated home budget for replacement but any needs are identified via the annual service review. Service users rooms are well looked after and homely. There are plans to improve the storage and furnishings in the bedrooms of some service users who have challenging behaviour. A previous requirement that the safety of the laundry room is reviewed and the poor state of the flooring and walls be addressed has been carried out. The laundry has been extended and the floors replaced and walls have been 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 19 made good. The manager said that the laundry is now more accessible to service users so that they can help with their washing. The home was seen to be clean and well cared for. Since the last inspection all staff have received infection control training and the manager said this has had a positive impact on domestic routines. 30 Broad Lane DS0000011147.V344530.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 excellent. This judgement has been made using available evidence including a visit to this service. Service users benefit from enough staff who are trained to meet their needs. Staff were positive about the developments in the way they work and can see the benefits for service users. A robust recruitment procedure is in place to make sure that staff are suitable to work with service users. Staff receive supervision and support in their work with service users. EVIDENCE: The home is well staffed by a team that is trained to meet service users needs. A training plan is kept to identify any training needs or when mandatory training needs updating. Training certificates were seen on staff files sampled. There is a stable core of experienced staff in the team and some new staff. The manager has worked with staff to develop care practice and provide a service that is more user focussed. Current staff deployment enables four support staff on duty between 9am to 9pm, one waking and one sleeping night staff. This level of deployment is needed to meet the diverse and complex needs of the service users. Since the 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 21 last inspection staff shift patterns have been reviewed to better meet service users needs. Rotas are planned so that there is a skill mix on each shift. It was clear that staff can see the benefit of the changes and that they strive to make a happy environment in which service users can make choices. Staff are recruited in line with Milbury’s recruitment procedure, which includes Criminal Records Bureau checks, references and health questionnaires. Staff files were sampled and a recruitment checklist shows that the procedure is carried out. Recruitment records are kept at head office by written agreement with the Commission and can be accessed if required. Staff spoken to confirmed that the recruitment procedure was carried out fully before they started work. Staff receive induction and training that meets national standards. There is a commitment to training in the staff team. Several staff have completed their Learning Disability Award Framework (LDAF) training and are waiting to take National Vocational Qualification level 3. Two staff are taking NVQ 3 and two are taking NVQ level 4. (Self funded). The manager plans to encourage more staff to take NVQ training and is looking at ways to improve access to this. There is a system of staff supervision in place and this was confirmed by speaking to staff and sampling staff records. Supervision is provided by the manager, deputy and two senior support workers and all have been trained to carry out this task. 30 Broad Lane DS0000011147.V344530.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 excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed and there are systems in place to seek the views of service users and others to develop the service. The manager has successfully promoted a more service user focussed culture in the home. Health and safety systems are kept up to date to keep service uses safe. EVIDENCE: The manager has National Vocational Qualification level 4 and relevant past experience in running a care home. She is not yet registered and has recently sent her application to Head Office to be forwarded to the registration team. There was good evidence from the written information supplied prior to the inspection and on the site visit that the home is well managed. There has been significant progress in staff development and user focussed care practice since the last inspection. The manager said she feels well supported by Head Office staff. 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 23 It was clear that the manager keeps up to date with training and practice developments but she does not have access to a work computer or the internet in the home. The CSCI and other websites are a vital resource for a home manager and service users confidentiality could be compromised if outside equipment is used. Milbury should review whether it should provide up to date computer equipment to enable the manager and staff to keep up to date with practice developments and maintain service users confidentiality. There is a Quality Assurance System in place that includes an Annual Service Review and surveys that are sent to service users, relatives and professionals. A copy of the outcome of this has been sent to the Commission. Development or improvement plans are generated from the Annual Service review. Feedback is also sought via staff and service users meetings. There is a Regional Quality Assurance Manager and the Line Manager carries out Regulation 26 visits. There is good evidence from the AQAA and site visit that health and safety systems are in place. The majority of health and safety records sampled were up to date and equipment is regularly serviced. The weekly record of hot water temperatures had some gaps while the manager was on holiday but she has taken steps to rectify this for the future. The thermometer used to carry out these tests only records temperatures as high as 50o centigrade and it is recommended that this is replaced by one that gives more accurate readings. There is a system for recording accidents and incidents and these records were seen on service users files sampled. Staff receive health and safety training and checklists are kept to monitor health and safety. 30 Broad Lane DS0000011147.V344530.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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 4 X 3 X X 3 X 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 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 YA24 Regulation 23(2) b Requirement Some bathroom and shower room flooring is in need of repair or replacement. Timescale for action 24/11/07 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 Refer to Standard YA22 YA23 YA37 Good Practice Recommendations More information needs to be recorded on the home’s complaints record to show more detail of the outcome of complaints dealt with by head office. That the manager also undertakes POVA level 2 training that is designed for staff who need to report incidents of alleged abuse. Milbury should review whether it should provide up to date computer equipment to enable the manager and staff to keep up to date with practice developments and maintain service users confidentiality. Replace the current hot water thermometer with one that gives more accurate readings. 4 YA42 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House, 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 30 Broad Lane DS0000011147.V344530.R01.S.doc Version 5.2 Page 27 - 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!