Inspection on 23/10/06 for 46-48 Meadowleaze

This inspection was carried out on 23rd October 2006.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

46-48 Meadowleaze 13/08/08

46-48 Meadowleaze 13/08/07

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 46-48 Meadowleaze 46-48 Meadowleaze Longlevens Gloucester Glos GL2 0PR Lead Inspector Mr Richard Leech Key Unannounced Inspection 10:00 & 23rd & 24th October 2006 08:00 46-48 Meadowleaze DS0000067084.V310682.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 46-48 Meadowleaze DS0000067084.V310682.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. 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 46-48 Meadowleaze Address 46-48 Meadowleaze Longlevens Gloucester Glos GL2 0PR 01452 530113 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.brandontrust.org The Brandon Trust Mr Jose Ignacio Fernando Serra Ubeda Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (4) of places 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27/03/06 Brief Description of the Service: The home is situated on the outskirts of Gloucester. Meadowleaze was formerly two adjoining semi-detached houses. Adaptations have been made to provide one detached property. There is a parking area at the front of the house, with ramped access to the front door and railings. The home is in keeping with other houses in the estate. All residents have single bedrooms, which are located on the ground or first floor. In addition there is a dining room and two sitting rooms, one of which has a television. Service users also have access to the kitchen. A stair lift has been fitted and there are other aids and adaptations throughout the home provided in accordance with people’s needs. Up to date information about fee levels was not obtained during this visit. The Statement of Purpose and Service Users Guide were about to be updated in order that they include all the information that a prospective service user may require. 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began on a Monday morning, lasting until late afternoon. A second visit was made on the following day from 08.00 to 12.00 in order to meet with the manager and another of the service users. All of the service users were met, along with many of the staff. Before the visit a pre-inspection questionnaire was returned, and several comment cards were received from people involved with service users’ care. During the inspection various documents were checked including examples of care plans, risk assessments, medication records, training summaries, daily notes and staffing files. The service has traditionally been inspected under the National Minimum Standards for adults (18-65). In view of the age of some of the service users consideration will be given in future inspections to assessing compliance with the National Minimum Standards for older persons also. What the service does well: Good systems are in place for planning care and for assessing and managing risks. Service users are supported to make choices and to take control of their lives as far as possible. Their rights are respected. People living in the home feel that they are listened to, and feel safe. Systems are in place which help protect people from harm and abuse. People living in the home are enabled to take part in a range of different activities which reflect their needs and interests. And are supported to stay in touch with friends and family. A varied diet which takes into account people’s preferences is served. Service users’ personal and healthcare needs are met sensitively, with people being treated as individuals. Support is provided by a skilled and appropriately trained staff team. A clean, homely and comfortable environment is provided. The team is exploring issues around the longer-term suitability of the environment for some of the people living in the home. Steps are taken which to make the home a safe place to live and work. Sound recruitment and selection procedures help to protect service users. The home is well run. 46-48 Meadowleaze DS0000067084.V310682.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. 46-48 Meadowleaze DS0000067084.V310682.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 46-48 Meadowleaze DS0000067084.V310682.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): 1&2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Outdated information in the Statement of Purpose and Service Users Guide may result in prospective service users and others involved in their care not being able to make a fully informed choice about moving to the home. The lack of an up to date admissions policy may compromise a fundamentally sound approach to referrals and admissions. EVIDENCE: The home’s Statement of Purpose and Service Users Guide were checked. It was agreed that these require review and update. For example, they refer to the former service provider, to being a service for ‘older adults’ and describe there being a smoking lounge, all of which have been superseded. Care should be taken to make sure that the updated documents comply with the relevant Care Homes Regulations (4 & 5) and that Standard 1 of the National Minimum Standards has been taken into account. At the time of the inspection there were vacancies in the home. One person was about to move in. The manager and staff described the admissions process. This included obtaining a community care assessment and other background information, offering visits and an overnight stay and recording these in detail, and allocating a keyworker who was making links with family 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 9 and existing carers. The person had chosen the colour of their new room. Initial care plans were being drawn up based on assessment information and meetings with the service users and others involved in their care. An admissions flowchart was viewed. However, the Trust’s admissions procedure dated from 2000 and should be reviewed and updated, for example to fully take into account the National Minimum Standards. At the time of the inspection the manager said that the service user due to move in had not been given a copy of the Service Users Guide. 46-48 Meadowleaze DS0000067084.V310682.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 at least once during a 12 month period. 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. A generally good care planning system operates in the home, helping to promote the quality and consistency of support. People’s choices are ascertained and respected as far as possible, helping to empower service users to take control of their lives. Arrangements are in place to assess and manage risks, helping to keep service users safe with minimal restrictions and limitations. EVIDENCE: Two service users’ files were checked in detail. These included up to date life histories, assessment information and a range of care plans. Care plans and guidance covered areas such as communication, healthcare needs, activities and mobility. In one case a significant change in the person’s condition had resulted in the suspension of the majority of their care plans and the introduction of new interim plans. Further assessment was to take place during their convalescence in order to establish the person’s longer-term care needs. 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 11 Staff indicated that work on the person’s care plans had slipped a little in the recent past but indicated that this would now be prioritised, particularly in view of the person’s condition. There were detailed monthly care plan reviews on file. The manager was aware that the Trust plans to introduce a new care-planning format throughout the organisation in the near future, with a more personcentred template. Care plans included an emphasis on establishing and respecting people’s choices, including the use of communication tools as appropriate. Staff cited examples, such as one person’s decisions around changes of clothing and service users’ freedom to spend money as they decided. This includes respecting choices such as people’s right to smoke if they wish. Staff were observed offering choices during the inspection, such as about food and drinks. Risk issues were seen to be assessed, reviewed and updated. These covered relevant areas and had a focus on enabling rather than restricting service users, although where necessary limitations were agreed. As noted, one person’s condition had significantly changed just prior to the inspection, resulting in new risk issues presenting themselves. There was evidence on file that the team had responded quickly to this change, engaging relevant professions and convening meetings to discuss specific areas such as mobility. Staff confirmed that difficult issues around the suitability of the environment were being considered. Discussion with staff and reading of older care plans and risk assessments provided evidence that service users had, when able, accessed the community independently. The Trust’s risk assessment policy was dated 1996 and would benefit from review. There was a missing person’s procedure dating from February 2006. 46-48 Meadowleaze DS0000067084.V310682.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, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate support is provided for people to take part in activities which reflect their needs and interests both in the home and community. Service users are also supported to maintain and develop contact with important people in their lives. Service users are respected and valued as individuals, promoting their selfesteem and sense of autonomy. A varied and balanced diet is provided, enhancing service users’ health and quality of life. EVIDENCE: A photographic activities timetable was on display in the home. This provided evidence of varied, individual programmes for people based upon their needs and interests. A range of facilities in the community were being accessed, providing people with opportunities to have meals out, meet friends, fulfil 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 13 spiritual needs and to have a variety of different experiences. The recent change in one person’s condition was impacting on their ability to access activities. The team were seen to handle this with sensitivity, helping the person to come to terms with this. Activity plans and daily notes provided evidence that service users accessed public transport. Within the home people were seen relaxing watching television and DVDs. One person described having a computer. A daytrip to a seaside resort was arranged for one person during the inspection. They described how much they were looking forward to it. Care plans and daily notes, together with discussion with staff provided evidence that links with family and friends were strongly supported by the team. This included visits, letters and telephone calls, as well as regular contact with friends being built into activities programmes. Surveys cards from family provided positive feedback about the service. Comments included that the care was excellent and standards high. Service users were seen moving freely around the home and making choices about where to spend time. Staff described how the people living in the home took part in day-to-day chores, seeing Meadowleaze very much as their own home. As noted, there was evidence of an empowering approach promoting independence and recognising people’s rights, although the change in one person’s condition was impacting on their support needs. Daily notes and discussion with staff and service users offered evidence of flexible routines, including times for getting up and going to bed. Records of what people ate were viewed. These provided evidence of a varied and balanced diet being offered, with records of people following individual menus according to their preferences. Service users expressed satisfaction with the food served in the home. One person said that the food was ‘very nice’ and indicated that they were offered choices. Staff confirmed that people sometimes made less healthy choices, such as biscuits for breakfast, but it was acknowledged that this was their right and reflected long-established patterns and preferences. 46-48 Meadowleaze DS0000067084.V310682.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal and healthcare needs are met in ways which reflect their needs and wishes. Suitable arrangements are in place for the handling of medication though there is scope to make aspects of the policy and procedure framework more robust. EVIDENCE: Care plans detailed how service users’ personal care needs were to be met. Staff spoken with described how they provided personal care support in ways which reflected people’s preferences as well as their needs, giving examples. They demonstrated an awareness of respecting people’s privacy and dignity. As described, one person’s support needs were in transition, and this will include care plans and interventions around personal care. Healthcare notes provided evidence that service users are being supported to access routine and specialist healthcare, including services from the Community Learning Disability Team and district nurses as appropriate. Some work had also been undertaken by the team around OK health checks and hospital assessments (which provide relevant information to in-patient teams if 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 15 the person has to go to hospital). Staff described good links with the local GP surgery. Healthcare services had been engaged around one person’s changed condition, considering issues such as mobility and falls. The manager and staff said that health action planning had been initiated, and that they had worked with the local implementation team. Some staff had been due to attend health facilitation training though this had been cancelled. It is recommended that work on health action planning for each service user be progressed in conjunction with others involved in their care. Positive feedback was obtained from a healthcare professional who had input into the home. Comments included that the team were very aware of issues around clients’ choice and that their recommendations were generally followed through. Medication storage and record keeping appeared to be in order. Training records and discussion with staff offered evidence that members of the team had received training and updates from a variety of internal and external sources, which accords with current CSCI guidance on attaining appropriate levels of competency in this area. Copies of up to date guidance about the handling of medication were available. However, the Trust’s medication policy dated from 2000 and was marked as pending review. It included reference to the Registered Homes Act. This review should be done as soon as possible since a variety of new guidance has been generated since then. A copy of some recent guidance about the use of medication to manage behaviour issues was forwarded for information. Staff described some changes to practice following a recent medication error. Some ‘as required’ medications were prescribed for service users. It is recommended that protocols be written about their use, in order to promote consistency in administration. 46-48 Meadowleaze DS0000067084.V310682.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for managing complaints, although aspects of policy need review in order that people have the information that they need. Systems are in place which help to protect service users from harm and abuse. EVIDENCE: The Trust’s complaints procedure dates from 2003 and consists of a text and symbol version. It is understood that this is going to be reviewed to make it more accessible. The home is keeping the procedure used by the previous provider in the meantime. The procedure also requires review since there are no contact details for CSCI included. Staff described how different people living in the home expressed dissatisfaction and how they responded to this. One service user spoken with confirmed that they felt able to speak up if they were unhappy, and expressed confidence that they would be listened to and the issue looked into. Feedback from families indicated that some were unaware of the complaints procedure. Copies could be forwarded for their information. The home has a policy about the protection of vulnerable adults dating from 2005. There is also a whistle blowing policy (dated 2000 and marked as pending review). A copy of the local ‘Alerter’s Guide’ was available in the home. 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 17 One service user was asked if they felt safe in the home and confirmed that they did. Staff spoken with demonstrated an understanding of their responsibilities around adult protection. They were clear that they would report concerns and that they would have confidence in systems for addressing these. Service users’ financial records were sampled. Those checked appeared to be in order. Some money was stored which belonged to a service user who had passed away. The manager explained the reasons for this and indicated that this would be dealt with in the very near future. 46-48 Meadowleaze DS0000067084.V310682.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 at least once during a 12 month period. 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. A clean, homely and comfortable environment is provided, promoting service users’ quality of life, although there are some concerns about the longer-term suitability of the environment for some of the people living in the home. EVIDENCE: All communal areas and most of the bedrooms were checked. The environment was homely and pleasantly decorated. Aids and adaptations were provided in accordance with specialist assessment. Service users asked expressed satisfaction with the home and their rooms. At the time of the inspection some redecoration and carpet-cleaning was taking place. The home appeared to be clean and hygienic throughout. Staff described the systems for cleaning the home and infection control measures. One service user said that the house was cleaned every day. 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 19 One bedroom door was propped open. This was an interim response to a change in the person’s condition and mobility. However, it was agreed that should the person continue to have difficulty opening their bedroom door then alternative arrangements would need to be made such as fitting an automatic closing device linked to the alarm system which would hold the door open safely. Linked to the above, the manager and staff openly discussed concerns about the long-term suitability of the physical environment for some people living in the home at the time. Clearly this will require ongoing consideration on an individual basis in conjunction with service users and people involved in their care. The manager said that a ground floor extension had been considered at one point. 46-48 Meadowleaze DS0000067084.V310682.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support is provided by a skilled and appropriately trained staff team, helping to ensure that service users’ needs are consistently met. Appropriate recruitment and selection procedures help to protect service users. EVIDENCE: Staff were observed to interact with service users in a warm and respectful manner. Service users appeared relaxed and comfortable in their presence and were seen to banter and share a joke. Staff were also seen providing skilled care interventions in respect of complex individual needs in a sensitive and supportive way. Service users were positive about the staff team and the support they received. The communication book provided evidence of good communication within the team. Staff spoken with also felt that communication in the home was good. Minutes from a staff meeting in August 2006 were seen. These showed that there had been wide ranging discussions. 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 21 There was individual communication guidance on file for each person. Staff were in the process of creating new guidelines for one person in conjunction with relevant healthcare professionals. Discussion and documents provided evidence that over 50 of the staff team (excluding the manager) have attained a National Vocational Qualification (NVQ) in care to at least level 2. A picture rota was on display in the home. The manager and staff said that overall staffing levels may require review in respect of changing needs and new admissions. The manager said that there had been no new staff since the last inspection. Some staffing files were checked. Some shortfalls were identified but it was accepted that the manager was not responsible since the person had been recruited for a different home in the organisation several years prior. The manager described the steps he takes when recruiting, demonstrating an understanding of the process and of his role as well as the requirements of the Care Homes Regulations. It was agreed that a copy of a CSCI report about recruitment and selection would be forwarded since the manager expressed uncertainty about some aspects of the process. Training records, along with discussion with the manager and staff offered evidence that staff were either up to date with basic training or that this was booked for the near future. In addition, training about the protection of vulnerable adults had recently been provided for all but two staff (who were booked to attend a session early in 2007). Some training in person centred planning had been booked for October 2006 but had unfortunately been cancelled by the training provider. The manager acknowledged that there may be some specialist training needs for the team related to people’s changing needs and conditions. It was agreed that, whilst there was evidence of appropriate training being provided the information was relatively difficult to obtain since the information was located in different places, records were not entirely up to date and copies of certificates were not consistently obtained. Consideration should be given to how to better organise training records such that information about training completed, booked and required is easier to locate. 46-48 Meadowleaze DS0000067084.V310682.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run, promoting positive outcomes for service users. Measures are in place which help to monitor and improve the quality of the service provided, though these should be further developed. Arrangements are in place which help to make the home a safe place to live and work. EVIDENCE: The manager is a qualified nurse in learning disability. He maintains his registration. He achieved the Registered Manager’s Award in 2004. Staff and service users gave positive feedback about the manager and indicated that the home was well run. This was confirmed throughout the inspection, as described in the different sections of this report. 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 23 Quality assurance was considered. Regulation 26 reports are being forwarded for each monthly visit made by representatives of the service provider. Minutes were seen of residents’ meetings, which take place about once a month. These cover areas such as menus and activities. The Trust has a series of quality standards and home managers have been asked to audit their service against these. It is understood that these standards are due to be reviewed to give more of a service user perspective, along with there being changes to the overall quality assurance strategy. At the time of the inspection the manager had not yet completed the self-audit against the standards. He had obtained a survey template from another service in the organisation and was seeking authorisation to use this with the people living in the home. As noted, regular and detailed care plan reviews were seen to be undertaken. Although this standard is assessed as met, there is scope for developing quality assurance in the service including finding other ways of obtaining feedback from people living in the home. Progress in this area will be considered during future inspections. The Trust has a health and safety policy dated 2005 and an accompanying file of information and procedures, though it is understood that further work is taking place on updating and simplifying this. Information was also available in the home about changes to fire safety legislation. Documentary evidence was available of tests of alarms and emergency lighting at suitable intervals. The last recorded fire drill was July 2006. It was agreed that these could be made more frequent, particularly in the light of changes to some people’s mobility. This may in turn result in changes to aspects of the evacuation procedure. The fire risk assessment on file was undated. It may require review in any case in respect of the changes described above. Records provided evidence of other routine health and safety checks being conducted including for aids and adaptations, central heating, hot water temperatures and fridge/freezer temperatures. 46-48 Meadowleaze DS0000067084.V310682.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 2 2 2 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 2 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 3 33 x 34 3 35 3 36 x 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 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 x 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 2 Standard YA1 YA22 Regulation 4, 5 & 6 22 (7) Requirement Review and update the Statement of Purpose and Service Users Guide. The complaints procedure must include the name, address and telephone number of CSCI. Timescale for action 28/02/07 28/02/07 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 4 5 Refer to Standard YA2 YA2 YA9 YA19 YA20 Good Practice Recommendations The Trust should fully review and update the admissions policy dating from 2000. Ensure that all prospective service users have a copy of the Service Users Guide. Review the policy on risk assessment dating from 1996. Continue to develop health action plans for each person living in the home. The Trust’s medication policy dated 2000 should be reviewed as soon as possible to take into account the National Minimum Standards as well as other relevant guidance such as from the Royal Pharmaceutical Society and Royal College of Psychiatrists. 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 26 6 7 8 YA22 YA35 YA42 Devise protocols for the use of each PRN medication. Distribute copies of the complaints procedure to service users’ family members in order that they are clear about how to complain formally. Consideration should be given to how to better organise training records such that information about training completed, booked and needed is easier to locate. As part of the overall fire risk assessment, consider whether the frequency of fire drills needs to be increased. Consider whether the fire risk assessment requires general review and update. 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 46-48 Meadowleaze DS0000067084.V310682.R01.S.doc Version 5.2 Page 28 - 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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