Inspection on 06/06/06 for 31 Wensum Way

This inspection was carried out on 6th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

31 Wensum Way 28/11/08

31 Wensum Way 13/11/07

31 Wensum Way 10/11/05

31 Wensum Way 03/06/05

31 Wensum Way 19/01/05

31 Wensum Way 08/07/04

31 Wensum Way 18/03/04

31 Wensum Way 18/12/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 31 Wensum Way Fakenham Norfolk NR21 8NZ Lead Inspector Mrs Lella Andrews Unannounced Inspection 6th June 2006 09:30 31 Wensum Way DS0000027503.V299217.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 31 Wensum Way DS0000027503.V299217.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. 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 31 Wensum Way Address Fakenham Norfolk NR21 8NZ 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) 01328 863440 NO FAX # Elizabeth Fitzroy Support Mr Graham Snell Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2005 Brief Description of the Service: 31 Wensum Way is a modern semi-detached house providing accommodation and care for up to eight people with a learning disability. The home has accommodation on both floors and access to the first floor is by a flight of stairs or the chair lift. The home is run as two units each providing living accommodation for four people. The bedrooms are all single rooms that contain a wash basin and the ground floor of the home has been designed and adapted to deliver a service to people with special mobility needs. On each floor there is a communal kitchen/dining room, a lounge, adapted bathroom and toilet and on the ground floor there is an additional shower room. The lounge on the ground floor has been made into a sensory/games room and there is a small room on the first floor for the use of those residents that smoke. There is a large well kept garden to the rear of the property that offers access to all residents and a pleasant area to sit and parking to the front of the building. The home is sited in a residential housing estate approximately half a mile from the centre of Fakenham which offers local health amenities, leisure activities and shops. The fees for the Home are approximately £850 per week. 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to the Home was carried out on the 6th June 2006 between 9.30am and 6.30pm. This visit formed part of the inspection process for this Home. Other information considered within this report are comment cards received from the people who live at the Home (7), relatives (9)and health professionals (1) as well as any other information notified to the Commission over the past year. The Manager of the Home is leaving in a fortnight to take up another role within the organisation. The management of the Home will be undertaken by the deputy manager and by another manager from within the organisation who will work at the Home part time until another manager can be recruited. The Operational Manager and the Manager who will be overseeing the Home in the short term were also present during the visit and for the feedback. Overall, this Home is run well and provides a good quality of care. It is run in the best interests of the people who live there. The views of the people who live at the Home are routinely sought and they are supported to make their own choices. All of the previous requirements have been met. What the service does well: The Home is well run with the Manager and deputy manager providing support to the staff team. Staff receive training and informal support to carry out their roles. The views of the people who live at the Home are routinely sought about all issues affecting them. The staff recognise the importance of effective communication and work hard to continually improve communication. The people who live at the Home are supported to access a range of leisure activities within the local, and wider, community. All seven of the comment cards from the people who live at the Home state that they like living at the Home, that they feel well cared for, that the staff treat them well and that they feel safe at the Home. All nine of the comment cards from relatives state that they are satisfied overall with the care provided. 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 6 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. 31 Wensum Way DS0000027503.V299217.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 31 Wensum Way DS0000027503.V299217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Quality in this outcome group is adequate. Procedures are in place to ensure an effective assessment process for people moving into the Home. There is a need to ensure that the statement of terms and conditions are individualised for each person and that they include the fees payable. EVIDENCE: No-one has moved to the Home in the last twelve months. However, the Home has suitable procedures for ensuring an effective assessment process is carried out prior to someone moving there. The Home has a statement of terms and conditions for the people living there but it is recommended that this contains the fees and any other charges made for services. 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 9 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, 7, 8 and 9 Quality in this outcome group is good. Overall, the care plans contain good, detailed information about how to meet the individuals needs. The views of the people who live at the Home are routinely sought. EVIDENCE: Three of the care plans were seen and these contain a lot of information about the needs and wishes of the individuals. The formats of the care plans are slightly different and the Manager said that these are currently being reviewed to find the most appropriate format for each person. The information is personalised and written in the first person. There is information about what the person might consider to be their “best” day and their “worst” day which gives a good picture of the actual person. The staff said that there have recently been some changes to the keyworker system and that now each person has a “key team” who a group of staff who work with the individual on specific issues. It is recommended that all of the care plans are reviewed to ensure that they include all of the details necessary 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 10 as there were a couple of issues which the staff spoke about which were not in the care plans. Five of the completed comment cards indicated that the people who live at the Home are aware of their care plan. One person told the Inspector that they know what is in their care plan and gave permission for it to be seen by the Inspector. Staff are aware of the care plans and of the information contained within them. They also complete daily diary entries which include information about what the person has been doing that day and any specific issues that may have arisen. Observations of and discussions with staff provide evidence that care is provided in a consistent way and that staff have a good understanding of the needs of the individuals. Detailed risk assessments are carried out for a range of issues and the staff are aware of these. The key teams are responsible for ensuring that these are kept up to date. It is recommended that the files in which care records are kept are reviewed and archived so that the information available to the staff on a day to day basis includes only that which is currently relevant. Staff recognise the importance of effective communication and are aware of how each individual communicates. Several of the people who live at the Home do not have good verbal communication skills and therefore use alternative forms. One of the staff has recently attended training and is now the communications co-ordinator for the Home. She is enthusiastic about this role and has already provided some training for the other staff and is in the process of assessing the communication needs of each person who lives at the Home. This work will be ongoing and will be of benefit to all. The staff were able to give lots of examples of how the views of the individuals are sought and how action has been taken to meet choices and wishes. Staff were seen to communicate effectively with the people who live at the Home and to offer choices in a range of situations. The people who live at the Home are encouraged to be a part of what goes on there. They are consulted about menus, activities, decoration and refurbishment as well as other issues affecting all who live at the Home. They are also encouraged to take part in household chores if they wish to. The kitchen on the ground floor has adapted surfaces so that the height of these can be adjusted as needed. The Home looks after money for the people who live there and an appropriate system of recording is in place. The records and money were checked for one individual and the current records were found to be correct. However, a small error had not been addressed even though it had been picked up through the 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 11 regular auditing process. It is required that the processes are reviewed to ensure that audits are effective. Each person has a detailed financial care plan which is good practice. 31 Wensum Way DS0000027503.V299217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome group is good. The people who live at the Home are supported to take part in a wide range of activities. Individuals nutritional needs are assessed and a choice of meals is offered. EVIDENCE: All seven returned comment cards from the people who live at the Home stated that they have lots of things to do. All attend day services away from the Home for at least three days per week, with most attending four days. Photographs, discussions with staff and the people who live at the Home provide evidence that support is provided for individuals to access a range of leisure activities away from the Home. These include shopping, meals out, holidays, cinema, football. The Home has a large vehicle suitable for transporting people in wheelchairs and two of the individuals have their own cars which staff are able to drive. The Home is located within walking distance of the town of Fakenham and staff 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 13 said that they often use the facilities there. Plans are in place for individual holiday arrangements and the staff described a range of options for these. Four of the relatives completed comment cards stated that there are not always enough staff on duty with additional comments that this means that the people who live at the Home go out less. Observations of the rotas and discussions with the Manager and staff confirm that recently there have been difficulties with staffing but that current recruitment should address this. All nine of the relatives comment cards stated that they are always made to feel welcome at the Home and that they are able to see their relative in private. Eight stated that they are kept informed about issues affecting their relative and all nine stated that they are satisfied overall with the care provided. All seven of the comment cards from the people who live at the Home state that their family and friends are able to visit them. The care plans include information about individuals family and friends and the arrangements in place to support the individual to maintain contact with them. The Inspector spoke to one of the relatives during the visit and they were very positive about the support provided at the Home. They gave examples of additional support provided by the staff which enables their family to maintain good contact with each other. Several people go home for overnight visits on a regular basis. The rights of the people who live at the Home are understood and respected by the staff. Staff were heard to talk to people in a respectful, kind and relaxed manner. There was lots of laughter between staff and the people who live at the Home. The people who live at the Home are able to choose whether they have a key to their rooms and currently four choose to do so. The care plans contain information relating to the nutritional needs and preferences of each of the people who live at the Home. It is recommended however that if a note has been made in a care plan that someone would benefit from healthy eating that there is clear understanding what this means by all staff to ensure consistency as currently there may be some inconsistencies in this area. The menus are planned with the people who live at the Home and there are separate menus for the ground floor and the “flat” on the first floor. Records are kept of the original menus and also a separate record of meals actually eaten for each person. 31 Wensum Way DS0000027503.V299217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 Quality in this outcome group is good. The physical and emotional needs of the people who live at the Home are met. Medication is managed effectively. EVIDENCE: The people who live on the ground floor have additional physical disabilities and all use wheelchairs to mobilise. Those that live in the flat on the first floor have emotional/mental health needs in addition to a learning disability. The care plans contain details about the physical and emotional needs of the individuals and how these should be met. The staff are aware of how these needs are to be met and the preferences of the individuals. The recommendation made under standard 7 also relates to a health issue. Whilst the staff are aware of the action to take in the event of a health crisis for one of the individuals the care plan is not detailed enough to provide this information to new staff. It is recommended that all staff attend the relevant training with regard to supporting people with a learning disability and a mental health need as not all have done so. 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 15 The comment card completed by the GP is positive and states that they are satisfied with the overall care provided. It states that medication is appropriately managed and that the Home communicates clearly and works in partnership with the practice. It does also state that there is not always a senior member of staff on duty which is true as all staff are encouraged to liaise with health professionals when they visit. The appropriate equipment is provided to ensure that the individuals needs can be met with as much privacy and dignity respected as possible. The staff are aware of the importance of offering choice to the people who live at the Home about the ways in which they are supported. Staff gave examples of how this is carried out in practice. As far as is possible personal support is provided by staff of the same gender. The young woman who lives at the Home, and her family, have been asked their views about male staff providing personal care on occasions if no female staff are available and a record is kept of this decision. A range of health professionals are involved in the lives of the people who live at the Home. Appointments are recorded in the care records and any guidance is incorporated in to the care plans. The Commission are appropriately notified of any health situations requiring notification as per regulation 37. The previous requirement relating to standard 21 (ageing and death) has been met as the Manager has discussed funeral plans with the people who live at the Home and their families. The care plans now contain these details where it has been possible to obtain them. Medication is managed effectively. It is stored appropriately and clear records are kept of medication received into the Home and that which is returned to the pharmacy. Records are also kept of medication which goes home with people when they are going for a visit and that returned. The team meeting minutes show that medication is audited regularly and that previous issues have been identified and addressed by the Manager. Recent changes have been made to the recording system following this process. 31 Wensum Way DS0000027503.V299217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome group is good. Individuals feel that their views are listened to. Procedures are in place to protect individuals from abuse. EVIDENCE: The Manager said that there have been no complaints made to the Home in the last year. The Commission have not received any concerns or complaints in that time either. Six of the comment cards from people who live at the Home state that they know who to tell if they are unhappy. Six of the relatives comment cards state that they are aware of the complaints procedure. The organisation has a complaints procedure and this is available around the Home and a copy can be provided to relatives or anyone else who would like one. The Homes policies and procedures aim to protect the people who live at the Home from all forms of abuse. Staff are clear about the need to report any concerns that they may have and are confident that the organisation will deal with these appropriately. All new staff receive training with regard to the protection of vulnerable adults within their induction. It is recommended that the Manager makes sure that all existing staff have received this training as it was not very clear from looking at training records. 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome group is adequate. The two areas of the Home meet the needs of the people living there but there are some areas in need of improvement. EVIDENCE: The Home is divided into two separate living areas. Four people with additional physical disabilities live on the ground floor and four people with mental health needs live on the first floor. There is a staircase linking the two areas of the Home. The previous requirement to replace the hall carpets on the ground floor has been met and the Manager advised that the hall carpets on the first floor have been identified as needing replacing and that this will be carried out shortly. The carpet in the activity room on the ground floor is also in need of deep cleaning or replacing and a requirement is made with regard to this. The two areas of the Home are suitable for the people who are living there. The ground floor has wide corridors and doorways with adapted bathrooms to meet the needs of the people with mobility difficulties. The kitchen has specialist equipment to enable people using wheelchairs to use the facilities. 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 18 The kitchen/diner in both areas of the Home are the centre of activity and where people choose to spend their time despite there being a large lounge on the first floor and an activity room on the ground floor. The activity room is currently mainly being used for storage of wheelchairs as the area previously used for this has been utilised for something else. The Manager said that this use of the activity room will be reviewed so that it is more inviting. Both areas of the Home have a washing machine/tumble dryer. The machine on the first floor was broken on the day of the visit but a new one has been ordered. The people who live in the Home are encouraged to do their own laundry if possible. The Inspector was told that, following a risk assessment, the windows on the first floor have window restrictors but two of the windows were seen to be open wide and so a requirement is made for constrictors to be on all first floor windows. 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 19 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 and 36 Quality in this outcome group is adequate. Staff are competent and enthusiastic about their roles. Following effective recruitment they receive training and informal support to carry out their roles. Staff numbers have been reduced recently due to problems with recruitment but this is expected to improve shortly. EVIDENCE: Staff who spoke to the Inspector had a good understanding of the need of the people who live at the Home. They are enthusiastic about their role and were seen to communicate positively with individuals. All seven of the comment cards from people who live at the Home state that they feel well cared for and that the staff treat them well. New staff attend a two week formal induction which covers a range of subjects. Staff receive updates in mandatory training subjects and there are additional training sessions that they are able to access via the organisation. Recommendations have been made previously in this report about training (see standard 19 and 23). The Manager said that at least 50 of the staff team either have achieved NVQ Level 2 or are in the process of completing it. 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 20 The staffing rotas confirm the information gathered from staff, relatives comment cards and the Manager which is that there is usually four members f staff on duty but that due to staff shortages there have been occasions when there are only three members of staff on duty. One member of staff works on the first floor and the others on the ground floor. The Manager said that they are currently recruiting for night staff and that some of the day staff have been doing additional hours to cover for the lack of night staff. When there are only three members of staff on duty it can be difficult to enable the people who live at the Home to go out, particularly on an individual basis. However, there are also times when at least one person has gone to visit relatives for the weekend and therefore there are less people at the Home. The Home now has a risk assessment in place to ensure that it is recognised when additional staff are needed on the first floor to support an individual when their mental health deteriorates. It is recognised that the management address recruitment difficulties as soon as they are able to and that there are no serious concerns about the staffing levels. However, this is the third consecutive report (over one year) which has identified the same situation and the organisation needs to look at this with a long term view rather than reacting in the short term. Following the requirement in the last report the recruitment files have improved and the ones that were seen during this visit included the necessary information. The organisation has appropriate recruitment processes. The staff said that they receive good informal support from the Manager and the deputy manager. There is also an on-call system in place for out of hours support. Formal supervision has not taken place on a regular basis and a requirement is made for this to be addressed. Staff have regular team meetings and said that they feel able to put forward their views at those. The Home also has a staff representative on the organisations staff forum. 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 21 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 and 42 Quality in this outcome group is good. The Home is well run with the deputy and Manager working together to provide support and leadership. A quality assurance process has started to be implemented. The health and safety of the people who live at the Home and the staff are, in the main, protected but there is a need to ensure that any problems are addressed more quickly. EVIDENCE: Discussions with staff provide evidence that the deputy and Manager both provide good support and leadership to the staff team. The Manager is leaving the Home in three weeks to go to another job within the organisation. The organisation will advertise for another Manager and in the meantime the deputy will be supported by another Manager from within the organisation on a 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 22 part time basis. The Operational Manager also provides regular support to the management team. The Home has several ways of gathering the assessing the quality of the service provided, for example, house meetings, staff meetings, Regulation 26 visits, care plan reviews, tenants forum, staff forum and the REACH standards. The Home has recently started to implement the REACH standards which are used as the quality assurance tool across the organisation. The Operational Manager is aware of the need to gather the views of stakeholders throughout the quality assurance process and intends to ensure that the annual report will bring together all the aspects of the process. In general, the health and safety of the people who live at the Home are protected, although it would have been expected that the broken window protectors on the first floor should have been identified and mended much more quickly. The Inspector saw the service/maintenance certificates for the moving and handling equipment and fire safety equipment. The Home has a health and safety committee who also link into the organisations health and safety forum. The Manager said that he orders copies of the published Inspection reports and sends the relatives, and anyone else who wants one, a copy following each Inspection. 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 23 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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 2 X X 2 X 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 24 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 YA7 Regulation 13 (6) Requirement It is required that effective audits are carried out in relation to the service users money It is required that the carpet in the activity room is deep cleaned or replaced It is required that the broken window restrictors on the first floor are replaced It is required that the staff receive formal supervision on a two monthly basis Timescale for action 06/06/06 2. 3. 4. YA24 23 (2) 13 (4) 18 (2) 30/09/06 30/06/06 31/07/06 YA24 YA36 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. Refer to Standard YA5 YA6 Good Practice Recommendations It is recommended that the statement of terms and conditions includes each individuals fees and any other charges eg. For transport It is recommended that during care plan reviews the care plans are archived and that the key teams ensure that all relevant information is recorded DS0000027503.V299217.R01.S.doc Version 5.2 Page 25 31 Wensum Way 3. 4. YA17 YA19 It is recommended that the dietary needs of those service users who are following a healthy eating plan are clarified in their care plans It is recommended that the training files are reviewed to ensure that all staff have received mental health/learning disability training and POVA training and that the records reflect the training undertaken by each person 31 Wensum Way DS0000027503.V299217.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 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 31 Wensum Way DS0000027503.V299217.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!