Inspection on 19/09/05 for 49 Stolford Rise

This inspection was carried out on 19th September 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

49 Stolford Rise 29/01/07

49 Stolford Rise 03/05/06

49 Stolford Rise 11/04/05

49 Stolford Rise 02/11/04

49 Stolford Rise 04/05/04

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

CARE HOME ADULTS 18-65 Stolford Rise (49) Tattenhoe Milton Keynes Bucks MK4 3DW Lead Inspector Maureen Richards Announced 19 & 20 September 2005 09:45 a.m. 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 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 Stationary 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. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Stolford Rise (49) Address Tattenhoe, Milton Keynes, Bucks, MK4 3DW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01908 505626 The Disabilities Trust Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 This home is registered for three people with a learning disability. Date of last inspection 11 April 2005 Brief Description of the Service: Stolford Rise is a residential home providing care and support to three service users with a learning disability. The home is located in a residential area of Milton Keynes. It is close to local shops and is on a bus route to Milton Keynes where a wider range of activites and amenities are available. The home consists of a two storey building. All of the bedrooms are single and each service user has a separate individual lounge area. At the rear of the property is an enclosed garden with seating. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced. It took place over one full day and part of a second day and lasted for a period of nine and a half hours. The inspection focused on some of the key standards and included formal one to one meetings with two staff, discussions with the manager, examining records and viewing some policies and procedures. The service manager was present on day one of the inspection. The three service users living at the home were out during the inspection. One comment card was received from a relative who indicated they were happy with the care provided. No comment cards were received from the service users or other professionals. What the service does well: What has improved since the last inspection? What they could do better: Medication practices must further improve to safeguard service users. The organisation must ensure that all staff are clear of their responsibilities to report any event to the Commission which affects the well being of service users. The organisation must ensure that all concerns raised are logged and addressed under the complaints procedure. The organisation must ensure that the vulnerable adult policy is updated in line with interagency procedures. The organisation must ensure that there are sufficient staff on duty at all times to meet service user needs. The organisation must ensure that safe recruitment procedures are followed and an immediate requirement notice was left at the home to inform the organisation that this must be addressed. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 6 The organisation must ensure that bank staff have all of the required safe working practice training. 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. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 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 standard(s) 2 The home has an admissions procedure in place, which ensures that they are able to meet the needs of service users admitted to the home. EVIDENCE: There have been no new admissions to the home since the previous unannounced inspection. The service manager confirmed that the clinical team employed by The Disabilities Trust and the registered manager do the initial assessment. Following this it goes to a panel for discussion and a decision. The panel considers the needs of the other service users living at the home and compatibility with each other. The service manager confirmed that the Trust has an assessment form, which is completed on assessment. This assessment form was not available at the home and the service manager agreed to send a copy of a blank assessment form to the Commission. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 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 standard(s) 6,7 & 9 Progress has been made in the development of service users plans, which ensures that service users needs are met in a safe and consistent way. Service users are supported to make decisions about their lives, which enables them to be involved in all aspects of their care and life at the home. Specific and generic risk assessments are in place, which promotes the health, safety and welfare of service users. EVIDENCE: All three service user plans were seen at this inspection. The service user plan is separated into two sections within the one file. All service user files contain a photograph and detailed information on the person and what they like and dislike. Service user plans include support guidelines on how behaviours are managed, support required when out shopping and cooking, support required with personal hygiene, support required in maintaining family contact and social activities and in the management of finances. Some service user plans included specific guidelines on the management of medical conditions and medications. Service user plans include a date of review and evidence of being reviewed and updated. In one of the service users plans seen some guidelines were overdue Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 10 for review. The manager was aware of this and was addressing it as the keyworker was off sick. Service user plans make reference to service users being involved and supported to make decisions which affect their day to day lives. All of the service user plans make reference to the level of support required by individuals with communication. The home has a monthly service users meeting and service users are encouraged to make decisions on aspects of their daily lives. Service user meeting minutes seen indicate discussions on choice of activities and service users being kept informed of changes within the home. The home has no advocacy involvement. Service users are encouraged to make choices and service user plans include risk assessments to indicate why it is necessary for staff intervention with some choices and decisions. Limitations on facilities and restrictions are outlined within individual service user plans. Service user plans indicate the level of support required with finances. The organisation does not act as an appointee for any of the current service user group. Some service users keep a small amount of money in the safe. All money put in and removed from the safe is recorded. The service manager confirmed that a recent financial audit has been carried out by the organisation and no issues were raised. Service user plans included a risk-screening tool and from this a series of risk assessments were put in place. A requirement was made at the previous unannounced inspection that the organisation must ensure that service users’ risk assessments clearly outline the level of risk and appropriate action must be taken to reduce that risk. The risk assessments seen included the level of risk and the action required to minimise the risk. Risk assessments showed evidence of being reviewed and updated. The home has a missing persons procedure. This was not viewed at this inspection. Standard 10 was not assessed. A requirement was made at the previous unannounced inspection that the manager must arrange for all service users information to be kept secure and confidential. This has been complied with. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 11 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 standard(s) 12,15, 16 & 17 Service users have an individual programme of activities and therefore their individual interests are taken into consideration. Family involvement and friendships are supported and encouraged to enable service users to develop and maintain appropriate relationships. Individual routines are outlined in service users plans, which promotes service users privacy. The home promotes service users choice and involvement in meals, providing them with a varied and balanced diet. EVIDENCE: Two service users are supported to attend a local college. None of the current service user group are interested in taking up a work placement. All of the service users have an individual weekly plan of activities included within their service user plan, which includes educational and leisure activities. During the inspection service users were out on individual leisure activities or being supported to attend college. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 12 All of the service users have family involvement. Family visits are welcomed and encouraged and service user’s go out for meals and go on leave with family members. Service users have made friends with service users from another home nearby and through the church. There are no restrictions on visitors. Service users can choose who they want to see and can see visitors in their bedrooms, in individual lounges or in communal areas of the home. The service manager confirmed that service users would be supported with personal relationships within a risk assessment framework and without impacting on other service users. Service users plans and individual weekly activity plans makes reference to daily routines which encourage independence and choice. The manager confirmed that staff enter service user bedrooms by knocking prior to entering and this is reinforced at induction. Service users have keys to their bedrooms but choose not to have a key to the front door. All of the post is delivered to a locked box in the office. Service users post is out in a tray in the office and given to them unopened. This was witnessed during the inspection. Staff support service users to deal with their post if required. Service users are called by their preferred name and service user plans make reference to this. Staff tend to work individually with service users and therefore engage with them and not exclusively with each other. Service users can choose when to be alone and when not to join an activity and daily handover records confirm this. Some areas of the home are kept locked for example store cupboards and garage and risk assessments are in place to indicate why individual service users have not got access to those areas. Service user plans and the weekly programme make reference to individuals involvement with housekeeping tasks and this continues to be developed. The manager confirmed that the rules on smoking, alcohol and drugs are outlined in the service users guide. There are no issues with this at the home. Service users have three meals a day with healthy snacks available in between. Service users help themselves to breakfast and lunch. The evening meal is planned and agreed with service users weekly. The staff continue to work with service users in developing their choices and trying new dishes. An alternative choice is available if someone does not like what is on the menu. Staff are responsible for cooking the evening meal with service user involvement. Service users can choose where to eat their meals but are encouraged to eat the main meal in the dining room as a group. The home does not have to cater for any special diets. The home is able to access the dietician for advice as required and one service user plan seen shows evidence of this. A record is kept of the weekly menu and of the main meal eaten. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 13 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 standard(s) 18 & 20 Service users are supported to meet their personal care needs and to access specialist healthcare services that meet their individual needs. Improvements have been made to medication practices, however some medication practices could compromises the health and safety of service users. EVIDENCE: Service user plans make reference to the level of support required by individuals in meeting their personal care needs. All of the service users are mobile and do not require assistance or guidance in moving and handling. Service users are encouraged to get up to attend college, specific activities or appointments and can choose what time to get up on the days that they do not have a specific activity. Service users choose their own clothes and staff prompt service users with their appearance. Service users have a choice of staff on shift to work with them. The manager has recently changed the keyworkers and confirmed that this was discussed with service users prior to it happening. Service users do not require any specialist aids. Service users can access any specialist support through the GP. Some service users have specialist nurse input. All of the service users have a keyworker and service user plans make reference to individuals routines, likes and dislikes. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 14 Two of the current service user group are on prescribed medication. Both of those individuals require staff to administer their medication. Service user plans makes reference to the level of support required with medication. The home uses the Boots blister pack system. A medication cupboard has been purchased and is in situ in the office. The medication administration records seen showed no gaps in the administration of medication. One service user’s medication administration record indicated a change to the medication. This change was handwritten on the medication administration record by staff but there was no reference in the service user file or in the health record as to who had initiated this change. Requirement made to address this. The home has a record of disposal of medication, which is signed by the pharmacy. A requirement was made at the previous announced inspection that the organisation must ensure that a homely remedies policy is developed and the home must establish with the GP that the use of homely remedies does not interact with individual’s prescribed medication. The service manager confirmed that the home does not have any homely remedies and do not intend to use homely remedies. Service users who require pain relief are prescribed pain relief as an as required medication. There was no stock of any homely remedies in the medication cupboard. Staff training files indicate that staff have had medication training on the 9th September 2005.The service manager confirmed that new staff are inducted into medication practices and are assessed prior to administering medication. One staff induction record seen indicated that this individual was assessed in November 2004 and was due to be reassessed in May 2005. This reassessment had not taken place. The manager to check all staff files and ensure that all staff have an up to date medication assessment carried out and a copy kept on file. It was noted in the communication book that one service user’s medication was omitted on 3rd July 2005 and that on the 17th July 2005 a service user had an epileptic fit whilst on leave resulting in his shoulder been dislocated. This was not reported to the Commission under Regulation 37 and it was not reported on the Regulation 26 report for that month. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 15 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 standard(s) 22 & 23 The home has a complaints procedure in place, however all issues raised are not logged which could potentially mean issues are not being addressed appropriately. Staff are aware and have had appropriate training to ensure the protection of service users. However the organisation’s policy is not in line with interagency procedures, which potentially puts service users at risk. EVIDENCE: The home has a complaints procedure in place with clear guidelines on who to contact including the Commission for Social Care contact details. The complaints procedure makes it clear that complaints will be responded to within 28 days. Service users have been given a copy of the procedure, which is kept on their file as they refuse to keep it in their bedrooms. The home has a log for complaints. There were no complaints logged. The Commission had been notified of a concern. The individual was advised to take this concern to the manager or a senior manager within the Disabilities Trust. There was no record of this on file. The service manager confirmed by telephone that she had been made aware of the issue but did not record it as a complaint or concern as she felt she was able to resolve it immediately. The organisation must ensure that all concerns raised are logged regardless of whether they are immediately resolved or not. One service user’s relative indicated on the comment card that they were not aware of the complaints procedure. The home has a copy of the adult protection procedure in place. This policy is dated October 2003 and was due for review in October 2004. A requirement was made at the previous announced inspection that the organisation’s Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 16 vulnerable adults policy must be developed in line with interagency procedures. This has not been complied with. The organisation’s adult protection policy indicates that in the event of suspected abuse of a service user that the staff member should discuss the situation with the relevant manager and or professional e.g. GP/ Consultant, whether an adult abuse investigation is appropriate. This policy is not in line with interagency adult protection procedures, which state that any allegation of abuse must be reported to the care manager who takes the lead and makes the decision on any adult protection investigation. This policy has not been amended despite requirements made at two previous inspection. Training records indicate that staff have attended adult protection training in September 2005. Staff spoken with were clear of their responsibilities in reporting any concerns. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 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 standard(s) EVIDENCE: None of the above key standards were inspected at his inspection. Both standards were assessed at the previous unannounced inspection. A requirement was made at the previous unannounced inspection that the organisation must make a planned maintenance and renewal programme available for the home. This was not requested at this inspection. The manager confirmed that plans are in place to decorate the ground floor area of the home. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34, 35 & 36 At times the home does not have sufficient staffing levels to meet service users individual needs, which could potentially compromise staff and service users safety. There are shortfalls in the recruitment practices, which could compromise the safety and well being of service users. The majority of staff have safe working practice training, however the bank staff member does not have all of the required training which could potentially put her and service users at risk. Staff are supervised and supported in their roles, which enables them to provide good quality care. EVIDENCE: The home has a newly appointed manager, four full time care staff and two part time care staff. At the announced inspection in November 2004 the home had a further half a post as part of the established hours. The home uses bank staff to cover sickness. At the time of the inspection one bank staff member was being used on a regular basis to provide one to one support out of the home for one service user. The home had two staff on sickness and the bank staff member and permanent staff were covering those shifts. Staff confirmed that they did not feel pressured to cover those shifts however they were Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 19 working a long day from 7.30 am until 10.00pm. The manager is also included in the numbers for at least two shifts per week. All of the service users require one to one support for most activities out of the home. One service user has extra funding provided to support this. The rota indicated that there were three staff on the morning shift three times a week to allow for one service user to have one to one support at college, however there are only two staff on shift on four mornings, each evening and at weekends. The organisation must review the staffing levels and ensure that sufficient staff are on duty at all times to meet service users individual needs and to bring the staff team up to the previously agreed staffing level. The manager and staff confirmed that they have regular team meetings. The last staff meeting was held on the 22nd July 2005. Four staff files were seen at this inspection. The staff files have been reorganised and made more accessible. One of the staff files seen did not include a full application form and did not include the signature page of the application form. There were two references on file but as the application form was incomplete it was difficult to establish the relevance of those references. This file did not include confirmation of residency and did not have a recent photograph or copy of passport. There was a separate file with other communication and correspondence, which was disorganised and further communication, and correspondence was kept by the administrator at the other home. One of the staff files seen was for a bank worker employed by the Trust in 2003. This file contained some evidence of training and identification. However this file did not contain an application form, or references and had a CRB, which was carried out by a previous employer. On day two of the inspection the remaining part of this file was made available from the administrator, however only one reference was on file and no CRB had been carried out by the Disabilities Trust. An immediate requirement was made that this individual could no longer work unsupervised in providing care. The other two staff files seen contained the information as required under schedule 2 and schedule 4(6). Requirements were made at the previous announced inspection for schedule 2 & Schedule 4 (6) information to be kept at the home for all permanent and bank workers. This requirement has not been complied with. A requirement was made that the organisation must establish if individual staff require a visa and a copy of the visa must be maintained on the staff members file kept at the home. This was not complied with for one staff file seen. All staff undergo a period of introductory training prior to commencing work at the home. This training includes some safe working practice training and training in autism and aspergers syndrome. Training records supplied as part of the pre inspection questionnaire indicate that all of the permanent staff have had safe working practice training and the bank staff member had some of the safe working practice training although training in first aid and food hygiene was outstanding for this individual. A requirement was made at the previous Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 20 unannounced inspection that all staff including bank staff have up to date safe working practice training. The manager has commenced supervision of all staff. Staff files and staff confirmed that regular supervision is now in place. Staff confirmed that they feel supported in their roles. Supervision records for the manager were not available. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of the key standards were assessed at this inspection. Standard 37 was not assessed however there is a newly appointed manager who has applied to the Commission to be registered. The manager has been involved in reorganising systems within the home and in supporting staff in their roles. Staff confirmed that they feel the manager is supportive and that she listens and acts on their concerns. Standard 39 was not assessed. However requirements have been made at previous inspections for the organisation to ensure that monthly regulation 26 visits are carried out and a report sent to the Commission’s office. Regulation 26 reports for July and August were not sent to the Commission and a letter was sent to the Organisation to remind them of their responsibilities. The service manager confirmed that this has now been addressed and the manager has been made aware to forward a copy of this report to the Commission on a Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 22 monthly basis. As outlined under standard 20 Regulation 26 reports should comment on significant events within the home. Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 x x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 2 1 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Stolford Rise (49) Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 24 yes 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 20 Regulation 13 Requirement The manager must ensure that any change in service users medication is recorded in the service users health record. The manager must check all staff files and ensure that all staff have an up to date medication assessment carried out and a copy kept on file. The organisation must ensure that all events which affect the well being of service users are reported to the Commisson and made referance to within the Regulation 26 report. The organisation must ensure that all concerns raised are logged regardless whether they are immediately resolved or not. The organisations vulnerable adults policy must be developed in line with interagency procedures. ( Previous timescales of 31st January 2005 & 15th May 2005 not met) The organisation must review the staffing levels and ensure that sufficient staff are on duty at all times to meet service users individual needs. The organisation must ensure 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Timescale for action 30th October 2005 30th November 2005 30th October 2005 2. 20 18 3. 20 & 39 37 4. 22 22 30th October 2005 31st December 2005 5. 23 13 6. 33 18 30th November 2005 20th Page 25 7. 34 19 Stolford Rise (49) Version 1.40 8. 35 18 that all staff files contain all information as outlined in schedule 2 & 4 (6).Staff must not work at the home until CRB clearance and referances have been obtained. ( Previous timescale of 31.12.04 not met) The organisation must ensure that bank staff have all safe working practice training.( previous timescale of 21st December 2004 & 15th May not met) September 2005 30th November 2005 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 Good Practice Recommendations Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 Page 26 Commission for Social Care Inspection Cambridge House, 8 Bell Business Park, Smeaton Close Aylesbury Bucks, HP19 8JR 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 Stolford Rise (49) 20050919_Stolford Rise_AI_Stage 4_S15082_V242256_H53_MR_ces.doc Version 1.40 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!