Inspection on 07/08/07 for 305 Cressex Road

This inspection was carried out on 7th 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 305 Cressex Road High Wycombe Buckinghamshire HP12 4QG Lead Inspector Kerry Kingston Unannounced Inspection 7th August 2007 10:30 305 Cressex Road DS0000069096.V344527.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 305 Cressex Road DS0000069096.V344527.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. 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 305 Cressex Road Address High Wycombe Buckinghamshire HP12 4QG 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) 01494 445239 01494 684821 Turnstone Support Mr Kim Lai Chew Care Home 7 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New Service Brief Description of the Service: The home provides twenty-four hour care for seven people of both sexes with learning and associated physical disabilities. The house is owned by McIntyre Housing Association and the care is provided by Turnstone Support. The service has been in existence for many years but was registered in March 2007 when it was transferred from the Health Authority to Turnstone Support, a private provider who offer care to people with diverse special needs. The house is two domestic dwellings that have been adapted into accommodation for seven people, there are three bedrooms on the ground floor and four bedrooms on the first floor. The first floor is accessed by steep staircases and is not accessible to those with physical disabilities or frailties. Communal accommodation is limited, including a small kitchen. There is a sizeable rear garden, which is not easily accessible to those with physical difficulties. There are adequate bathing and toileting facilities. The home is approximately two miles from the town centre and there are local facilities within walking distance. The home has its own vehicle and residents are able to access public transport. The fees are approximately £1,317.02 to £1,324.86 per week for care and housing services. 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report for the first key inspection of the service, which included a routine unannounced site visit. This took place between the hours of 10.30am and 6.00pm on the 7th August 2007. The information was collected from an Annual Quality Assurance Assessment, a document sent to the home from the Commission for Social Care Inspection and completed by the manager, surveys which were sent to people who use the service, other professionals and families of residents. Two surveys were returned to the Commission, one from another professional and one from a family member. Discussions with two staff members, the registered manager, the area manager and three people who use the service took place. Other people who use the service were spoken to during the inspection visit. Only one resident is not able to verbally communicate so some time was spent observing interactions between her and staff. A tour of the home and reviewing residents and other records were also used to collect information on the day of the visit. The home transferred from the Health Authority to Turnstone Support in March 2007 and the home is continuing with transitional and development work created by the transfer. All areas of care, with particular regard to the care plans and record keeping are under development, with development goals and plans in place being generally adhered to. What the service does well: The home makes sure that they are able to meet the needs of the people who live there. The staff help people to make decisions and choices for themselves. People are helped to do as much as they can for themselves, as safely as possible. The home tries to make sure that people have plenty of things to do so that they enjoy their life and do not get bored. People are helped to keep in contact with their families and people who are important to them. The home makes sure that people are given their medicine safely. Staff are good at helping people who live in the home and are given training to make sure that they know how to meet everybody’s needs. 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 6 The home is well managed by a manager who has done it for a long time and is good at making sure that the people who live there are looked after properly. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 7 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 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5. People who use the service experience adequate quality outcomes in this area. The home has produced an up-to-date Statement of Purpose but the people who use the service do not have a Service User Guide to tell them what they can expect from their care and how much it costs. People have a recent assessment so that the home is sure that it is able to meet their needs. They are not, currently, involved in making choices or decisions about their future accommodation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An up-to –date Statement of Purpose is in place, it was developed prior to registration in March 2007. Service User Guides are still being developed and people do not have an individualised one to tell them what they can expect from the service and about the costs of the care being given. The cost of the rent and services provided by the housing providers (McIntyre Housing Association) are included in individual Licence agreements, which have been produced in user-friendly formats. 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 9 Peoples’ needs were re-assessed in January 2007 prior to transfer to the new provider, the assessments were completed by the prospective providers and the care managers. The residents are not aware of future housing developments, at this time. 305 Cressex Road DS0000069096.V344527.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 and 9. People who use the service experience good quality outcomes in this area. Each person has a limited individual care plan to ensure that staff know how to support them. Care plans are in the process of being completed that will enhance the information provided to inform everyone about the needs and preferences of the residents. Risk assessments are completed to ensure that residents can remain as independent as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans for four residents were seen. New paperwork has been developed that will provide much more detailed information about peoples’ needs and how to meet them. Much of the new paperwork is awaiting completion, the staff team are working to a plan with specific dates to complete the new care plans. Staff are, currently, using old care planning formats from the previous providers for their day-to-day work. These are not person centred or 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 11 comprehensive but provide an adequate working tool for staff to use to provide care for individuals. A Key worker is identified for each person and they are aware of their responsibilities. Peoples’ diverse cultural, religious and other special needs are addressed in individual plans, these will be clearer when the new care planning paperwork is fully operational. There is evidence that residents are more involved in the day to day running of the home, such as peoples’ food choices noted on the menu, for the past two months. Three residents said that they could choose what they wanted to eat, decide what they wanted to do and sometimes choose who they wanted to help them with tasks. A staff member felt that the strength of the home was the amount of choice people got and that they were supported to make decisions for themselves. One resident has an advocate who visits weekly. The new care plans include residents finances, how they are managed and how people will be helped to be as independent as possible with regard to their finances, however finances are not yet clear as transfers of money, appointeeships and other financial arrangements are still awaiting completion. Agreements with people such as ‘keeping information about me’, ‘holding spare keys’ and ‘ medication administration’ are held in files and signed by residents or their representatives. People who are able write their own daily notes and some of their own records, with staff assistance. Residents meetings are held monthly with most residents in attendance, these have been held regularly since March 2007. Minutes are kept and include the passing of information and listening to peoples’ views about the home. Risk assessments are in place, they were up-dated in July 2007 and include household chores and community presence, to ensure that people can be as independent as possible. It was discussed with the manager that he needs to ensure all necessary basic risk assessments are in place such as the use of ‘cot sides’. 305 Cressex Road DS0000069096.V344527.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): 12,13,15,16 and 17. People who use the service experience good quality outcomes in this area. People are able to choose their daily activities and are supported to be involved in the community and lead an interesting and rewarding lifestyle, according to their individual needs. Activities are not always properly recorded and activity plans/programmes are not in place. People are helped to stay in contact with their families and friends, where possible. Nutritious food is provided but people have a choice about what they eat and where they eat it. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does not have written daily activity programmes or plans but people attend day centres if they wish. People attend different day centres that suit their diverse needs such as an Age Concern service, a learning disability 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 13 service and the day centre next to the home. Three people confirmed that they enjoy attending their day services and one showed me some of the craft work that she had completed at the service, she said that she attends the day centre every day, really enjoys the centre and goes on holiday and to the cinema and to church if she wants to. Two people choose not to attend day services and direct their own activities, however, there are no written plans or programmes to introduce activities that they may enjoy. One resident said that she prefers to be at home and has plenty to do although she does sometimes ‘get bored’. She explained that she goes to dance classes, out shopping with staff, goes into the community independently and enjoys outings and holidays. The other person confirmed that he chooses not to go to day services but has enough to do and doesn’t get bored. He said that he accesses the local community independently, goes on holiday, goes to town with staff and enjoys outings with staff and others. Activities and outings are not always properly recorded although activities, as described by the manager and staff, were confirmed by residents. The home has a minibus suitable for use by people with physical disabilities and taxis are also used for transport. All but one person has family connections, families are invited to reviews, as appropriate and are part of the annual Quality Assurance surveys. One person who does not have family contacts has an advocate who visits weekly. Another resident visits her family every two weeks and another resident confirmed that staff help her to keep in contact with her family by telephone and writing, as they live some distance form the home. Three people commented that it was ‘a good place to live’, one said that ‘staff are good, will listen to you and will help you if you need it’, another said staff are good and friendly and will help you with anything’. One person commented that she has her ‘own keys and writes her own records, is happy in the home and can choose what she wants to do.’ Menus seen were balanced and nutritious, residents’ food choices were clearly noted on the menu. The quality of menus has improved substantially over the past few months, the manager advised that there is further development work around menus and giving choices to people and he is intending to use pictures and photographs in the future. Peoples’ nutritional needs are noted and weight charts are kept, as necessary. Residents confirmed that they have alternatives if they wish or if they don’t like the meal. People said the ‘food is good, you can have what you like if you don’t like what is on menu, you can eat it where you like.’ One person who needs help with meals was observed being assisted sensitively and appropriately. One person was given his meal in bed as he felt poorly and one person ate in her room, as that was her choice. 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 14 Shopping is done every two days so that residents can go shopping with staff and connect the meals with the shopping that is being done, this also alleviates the shortage of storage space. 305 Cressex Road DS0000069096.V344527.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 and 20. People who use the service experience adequate quality outcomes in this area. The home meets the personal and health care needs of the people who live there but care plans do not clearly describe peoples’ preferences and likes and dislikes and how their emotional needs are to be met. The home ensures that medication is administered safely to the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Current care plans include information about peoples’ likes/dislikes and preferences but they are not very detailed or person centred. A new care planning format has been developed to address these issues but they are not yet complete (see Individual Needs and Choices). Three people said that ‘they chose when to get up, go to bed and what to do and staff are around whenever they wanted help.’ All residents have a key worker allocated to them and the home offers same gender personal care whenever possible. The home has a cross gender care policy, which discusses the privacy and dignity of individuals. 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 16 People are supported to attend church and their religious cultural needs are noted on care plans, the home has an equality and diversity policy in place. The home has no behavioural guidelines to show how they assist people with their emotional and developmental needs, such as lack of motivation and not wanting to participate in activities, distress about a failed relationship or displaying aggressive behaviours. It was not clear what staff are doing to help people with these issues that are obviously causing emotional distress to themselves and others. Health records are kept but a substantial number have been archived and as the new health plan formats are not yet in place healthcare plans and records are very limited. The manager advised that all residents had a well person and drug review in February 2007. On the day of the inspection visit one person attended the opticians and a district nurse visited someone who was feeling poorly. Medication is kept in a locked metal cabinet, it is administered by two people whenever possible using the Boots Monitored Dosage System. The pharmacist does not visit but is always available on the telephone, the manager completes monthly audits of medication, there has been only one minor medication error in the past year. Medication records seen were properly completed and accurate. Staff have to have received training and be assessed as competent by the manager before they can administer medication. There are robust guidelines for the administration of medication prescribed to be taken ‘when necessary’ and these are signed by the GP. Guidelines include how people show and express pain. Medication is not used to assist with behavioural control, at this time. There is a comprehensive medication policy and procedure, which includes reviewing whether people can administer their own medication independently. 305 Cressex Road DS0000069096.V344527.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 and 23. People who use the service experience adequate quality outcomes in this area. The home has a robust complaints procedure and residents feel safe and protected by staff. The home does not have written guidelines to help people with any behaviours that may cause them and others distress. The procedures and systems for dealing with peoples’ finances are not fully in place yet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a robust complaints procedure, which has been produced in a user-friendly format, there have been no complaints since registration in March 2007. Three people said that ‘they know who to talk to if they are not happy, that staff listen to them and try to sort out any problems that they have’. There have been no safeguarding adults incidents since registration in March 2007. Three residents said that ‘they feel safe in the house, one person described an incident that had occurred in the community and how staff had helped her to make sure she was safer when accessing the community, independently. Two people described another resident’s behaviour making them feel scared and unhappy but confirmed that they felt staff would keep them safe. 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 18 Staff have received Protection of Vulnerable adults training and are currently embarking on refresher training. A staff member described what she would do and how she would deal with any concerns she had with regard to the safety of people in her care. The Commission has received no information with regard to complaints or safeguarding adults issues about the home. One person who has difficult behaviours does not have any behavioural guidelines, two others say that they are frightened by these behaviours. No guidelines are in place to minimise the behaviours that cause others fear and concern (see Personal and Healthcare support.) The manager advised that the home does not use any form of physical restraint. The financial affairs of the service users have not been completely resolved as yet. There are to be several systems with one person looking after his own finances, some having family members as appointees and the local authority acting as receivers on behalf of the court of protection. It is not clear how residents will be made aware of their overall financial situation, including their income and expenditure when all the financial arrangements have been resolved. Cash records seen at the inspection visit were well kept and accurate. 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 19 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 and 30. People who use the service experience adequate quality outcomes in this area. The environment has improved over the past few months it is cleaner and some decoration has taken place. It is an adequate environment for those residents who do not have physical disabilities or frailties, staff do their best to minimise the impact of the environment on those whose needs it does not meet. The inadequacies of the environment are to be addressed by the providers, by the end of October 2007. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The house has small communal areas, the kitchen has room for only one resident at a time to be involved in the cooking and domestic chores and the sitting and dining area has limited space. There is a further communal room, which is also small but affords a space for quiet dining or leisure time for residents. 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 20 The staff team work hard to minimise the impact of the environment on the care of the residents by such methods as assisting them to access the garden, persuading only one person at a time to be in the kitchen and ensuring bedrooms are comfortable and individualised so that people are happy to spend time in their rooms if they wish for some quiet time. Three people who live in the house have physical disabilities or frailties, their access to indoor and outdoor areas is limited as the house has steps into the back garden and steep stairs indoors to the first floor. The suitability of the home to meet the needs of those people with physical difficulties is the subject of an agreement made between the Commission and the providers at registration in March 2007. Some areas of the house have been re-decorated and new soft furnishings have been purchased for some communal and private areas. The house is generally clean and tidy but toilet bowls were seen to be dirty, the manager agreed to rectify this issue immediately. Two people said that ‘the house is much cleaner than it was, it looks really nice now some painting has been done and it’s a much better place to live.’ Clinical waste bins are supplied in the bathrooms but the cross infection policy with regard to the use of protective aprons and gloves was not evident. Staff are aware of a resident who has a specific condition that makes cross infection prevention necessary but there are currently no generic or specific guidelines in place. 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 21 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): 32,34 and 35. People who use the service experience good quality outcomes in this area. The home has a small team of staff who are well qualified and competent to meet the needs of the residents. Staff are offered opportunities to complete professional and vocational training to enhance their skills and knowledge. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff team consists of seven staff and there are three and a half vacancies, the shortfall of staff is made up by agency and bank staff. The manager minimises the disruption to residents by using the same agency and bank staff, whenever possible. The providers are currently embarked on a recruitment campaign but recruiting good quality staff has been an ongoing issue over a period of years. There are a minimum of two staff per shift, as many of the people are independent with their personal care needs and attend day care activities, outside of the home, for up to five days a week. The staff have good sickness records and there was no concern about staffing levels expressed by staff or residents, two people said ‘that staff are always around to help if you need it.’ 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 22 There is one waking night and one sleeping in staff. Three staff files were seen which confirmed that the home has the necessary information to ensure that all safety checks have been completed, prior to staff taking up their post. The provider offers a comprehensive training programme, which includes all mandatory health and safety courses. The training programme also includes Protection of Vulnerable Adults, medication, value- based practice, working within professional boundaries and epilepsy. All staff have an individual training profile, set against the home’s training needs analysis. Three of the seven staff have an N.V.Q.2 or above qualification and a further two have applied to start their professional training course this year. Staff spoken to and the manager confirmed that the organisation provides good training opportunities. One staff member, who had been in post for approximately four months, confirmed that she had completed a thorough induction programme, had accessed a minimum of four courses and has made an application to embark on N.V.Q.3 training. 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 23 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 and 42. People who use the service experience good quality outcomes in this area. The home is being well managed through a period of change, the manager and staff team are working hard to ensure that the changes have a positive impact on residents’ care. A quality assurance system is in place and will be operational, as appropriate. Residents are generally kept as safe as possible, but there are some safe working practice risk assessments that need to be put in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post for several years, he was registered in March 2007. He advised that he has almost finished the Registered Managers’ Award, having only one more unit to complete. Two residents told me he was ‘great’ ‘a good manager.’ 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 24 The service is being managed through many changes resulting from the transfer of the home from the Health Authority to a private provider. This transition has been well organised and the staff team are continuing to work hard to meet the target dates set on the programme for change. Progress is being been made towards ensuring that the agreement reached with the Commission at registration will be complied with, with regard to the environment. The Quality Assurance information gathering systems are being used to obtain feedback from residents, carers/relatives, and staff, the responses from service users to the surveys are due back by September 2007, other responses are collected at different times throughout the year. The information collected will be collated and changed into an annual report, which will be formulated to an annual development plan for the coming year. Monthly Regulation 26 visits take place and a report of the visits is provided to the home. The Regulation 26 reports include relevant comment on all areas of care practice and is reviewed, as necessary, at subsequent visits. All necessary policies and procedures are in place and are currently being assimilated by staff in the home. A sample of health and safety records was seen, most safety certificates were issued prior to registration. The home does not have all the necessary safe working practice risk assessments such as lifting and handling and infection control. The manager and area manager advised that these are being completed by the Health and Safety advisor and will be available imminently. The manager was advised that the safety of the showers should be reviewed with regard to high water temperatures being recorded, on occasion. The home completes a monthly Health and Safety audit and can ask for advice from the Health and Safety advisor for the organisation. 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 25 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 CONCERNS AND COMPLAINTS CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score Standard No 22 23 Score 3 2 2 3 X 3 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000069096.V344527.R01.S.doc LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 305 Cressex Road Score 2 2 3 X 3 X 3 X X 2 X Version 5.2 Page 26 New service. 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 YA1 Regulation 5 Requirement To provide the people who use the service with a Service User Guide that includes a Statement of Terms and conditions, so that they know what to expect from the care they receive and the costs of that care. To develop Healthcare plans that clearly show healthcare needs and appointments made to meet those needs. They must be of a quality to enable staff to monitor peoples’ health and address any health issues promptly. To include emotional health, including behavioural guidelines, in the care planning process to ensure that any issues, which cause the people who use the service distress, are dealt with as effectively, as possible. 3. YA24 23(1) & (2a) To adhere to the agreement reached with the Commission at registration so that a suitable living environment is provided for those people with physical disabilities or frailties. DS0000069096.V344527.R01.S.doc Timescale for action 01/10/07 2. YA19 12 (1) 01/10/07 01/11/07 305 Cressex Road Version 5.2 Page 27 4 YA30 13 (3) To develop generic and specific guidelines to protect the people who use the service from cross infection. To provide all the necessary safe working practice risk assessments (particularly lifting and handling) so that the people who use the service are kept as safe as possible. 01/09/07 5 YA42 13 (4) 01/09/07 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. Refer to Standard YA6 Good Practice Recommendations To complete the new care plan format as soon as possible so that staff will be able to offer and evidence person centred planning, including peoples’ involvement in the process. To develop activity programmes and plans and record those activities so that it is clear what people have done and if they enjoyed doing it, to aid in future planning. To ensure the new care planning paperwork shows clearly, peoples’ likes/dislikes and preferences with regard to the way their care is delivered. To make sure that people know what their overall financial status is, including their income and expenditure so that the manager can assist them to protect themselves from any form of financial abuse and help them to make informed choices with regard to their expenditure. 2. 3. 4. YA13 YA18 YA23 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 28 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 305 Cressex Road DS0000069096.V344527.R01.S.doc Version 5.2 Page 29 - 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. 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