Inspection on 29/01/07 for 49 Stolford Rise

This inspection was carried out on 29th January 2007.

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

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

Other inspections for this house

49 Stolford Rise 03/05/06

49 Stolford Rise 19/09/05

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) 49 Stolford Rise Tattenhoe Milton Keynes Bucks MK4 3DW Lead Inspector Barbara Mulligan Unannounced Inspection 29 January 2007 09:30 th Stolford Rise (49) DS0000015082.V322925.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 Stolford Rise (49) DS0000015082.V322925.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. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stolford Rise (49) Address 49 Stolford Rise Tattenhoe Milton Keynes Bucks MK4 3DW 01908 505626 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) The Disabilities Trust vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for three people with a learning disability. Date of last inspection 3rd May 2006 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 activities 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. Service users are able to access the services of other health care professionals through their GP at the local surgery. Milton Keynes hospital is within a 5-mile radius of the home. The current fees range from £1200 per week to £1500 per week. Information regarding the services offered by the home are available within the statement of purpose, which is available on request. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken on Monday 29th January 2007 at 09:30am. The visit consisted of discussions with the Home Manager, Unit General Manager, care staff and service users. A tour of the premises and an examination of the homes records, policies and procedures was undertaken. The inspection officer was Barbara Mulligan. The Home Manager is Sue Burge. Twenty-five of the National Minimum Standards were assessed during this visit. Twenty-two of these are fully met, and three almost met. As a result of the inspection the home has received one requirement. No comment cards were received from service users, relatives and/or representatives. Comments received, from people interviewed, expressed satisfaction with the care received from support staff. Some positive comments received include “my life here is better than it ever has been” and “the manager is very good and has made lots of improvements”. However some dissatisfaction was expressed regarding staffing in the home. Comments include, “We are very dependant on our regular staff because bank staff do not know the routines of the home” and “Some staff do not allow me to say I don’t believe in God”. The evidence seen and comments received indicate that this service does not always meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. The inspector would like to thank the registered manager and the responsible individual, the staff team and service users and relatives for their cooperation and assistance during this inspection. What the service does well: The home provides a pleasant and comfortable environment in which service users live. Individuals are encouraged to personalise their rooms with their own personal belongings. There are adequate levels of staff on duty who endeavour to meet the personal and healthcare needs of service users. Service users receive good healthcare support via regular routine consultations. Risk assessments are detailed and thorough. These cover the risks associated with assisting with medication and other health related activities. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 6 The staff team are motivated, undertaking relevant training and working towards their National Vocational Qualifications. Medication is well managed at the home. There is good support for the home by the provider organisation, with effective monitoring and quality assurance systems in place. There is an effective complaints procedure with all complaints and concerns being acted upon promptly, within stated time scales. What has improved since the last inspection? What they could do better: Staff interaction with service users does not always appear to be appropriate or respectful. The cultural diversity of the service users living in the home does not appear to be consistently met. Unresolved staffing issues at the home are preventing service users receiving the support they need to fully meet their individual needs. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential service users receive a thorough needs assessment undertaken by staff trained to do so ensuring that the home can meet all the care needs requirements of service users. EVIDENCE: No new admissions had taken place since the last inspection, or indeed for some time, so direct evidence of the management of new admissions was not available for scrutiny. The unit general manager stated that the organisation is presently in the process of reviewing the admissions policy. It was confirmed in discussion with the home manager and the unit general manager that any new admissions would receive a full assessment by staff trained to do so. This will include a psychologist and the home manager will be involved in the assessment process. Introductory visits and overnight stays would take place prior to any final placement decisions. The views of existing service users would be taken into account. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and consistent care planning systems are in place that provides staff with adequate information they need to satisfactorily meet service users needs. Service users make decisions about their lives, with assistance and communication support, that allows them to influence their lifestyle and how the home is run. Service users are supported to take responsible risks within the context of the home’s risk assessments and risk management strategies that ensure service users can have independent lifestyles. EVIDENCE: The home provides individual plans of care for each service user living at the home and these appear to be used as a working tool. Care plans were seen to be detailed and include a pen picture, information regarding daily living, specialist intervention, information about cultural needs, behaviour management plans, information regarding personal care and likes Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 11 and dislikes. Care plans were found to be comprehensive and acknowledge the holistic needs of the service users. Care Plans demonstrate lots of service user involvement and demonstrate a person centred approach. These plans are in line with the service users current needs. Each plan of care demonstrates good evidence of how service users prefer support to be implemented. There is good evidence of health screening taking place and how the home supports service users to access health advisors. The home ensures that each service user plan is reviewed regularly and involves the individual and where agreed their family or representative. Care Plans are updated During the previous inspection concerns were identified regarding the compatibility of the service user group and the break down in relationships and how the staff team addressed this. A requirement was issued for the organisation to address the issues of conflict between service users in the home and must ensure that service users are still satisfied with their placement. The home manager was asked how this had been resolved. She said that daily group discussion is encouraged and all grievances are aired. Regular house meetings are held to encourage all service users to make their views known and are encouraged to make decisions about the day- to- day running of the home. On the day of the visit there was good camaraderie observed between service users and the inspector was informed by one individual that “my life here is better than it ever has been”. The home operates monthly house meetings. Minutes are kept of these that demonstrate how individuals are the opportunity to make informed decisions about their lives and how choices are made. The key worker is responsible for supporting the service user in achieving the objectives set. Risk assessments are in place and examples seen include assessments for personal care, medical and health support needs, personal finances, using electrical equipment, washing and ironing clothes and trips out. All risk assessments were found to be up to date, signed and dated by the author. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are able to access a wide range of amenities which meet their social, leisure and spiritual needs. Although the home tries to promote the racial and cultural diversity of the service users, not all care staff appear to do so, resulting in the equality and diversity needs of some individuals left unmet. The unit promotes ‘flexible’ visiting and the daily routines of the home promote individual choice, providing service users with the ability to be as independent as their needs allow. Staff interaction with service users does not always appear to be appropriate or respectful, which could result in service users rights always being respected. Service users are supported to develop their own menus and participate in some cooking tasks, which promotes independence and choice while at the same time reinforcing independent living skills. EVIDENCE: Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 13 At the time of the inspection there were no service users undertaking any occupational training, further education or any distance learning. However, the home manager stated that if individuals wished to do so then this could be facilitated. Each service user has a weekly activity plan based on his or her wishes and needs, and they are all encouraged to practice skills for daily living. This includes support to undertake household chores, laundry, using public transport and personal finances. There is evidence in personal files that service users attend local amenities such as the cinema, shops, bowling, public transport, local pubs and restaurants. Two service users are members of private gyms and attend these regularly. All individuals living in the home are encouraged to be politically active and they all vote. Concerns were raised by a service user regarding some staff not allowing him to express his non believe in God. This does not reflect the cultural diversity of the service users living in the home and must be addressed. Families and friends are welcomed into the home. Service users can choose whom they see and can see visitors in their own rooms, in private, if they wish. There are no restrictions about family and friends visiting. Staff knocking on bedroom, toilet and bathroom doors maintains the privacy of individuals. All service users open their own mail and this was observed on the day of the visit. Preferred term of address are used for service users and this is recorded in the care plans. Most care staff seen interacting with service users do so with respect and in a manner that is appropriate to the individual. However this does not appear to be the case with all care staff and a lack of interaction was observed with some care staff on the day of the inspection. The home manager must address this with the staff team. Service users choose their own menus and are supported to prepare and cook meals. Staff support individuals to make healthy choices. On the day of the inspection the unit general manager and the inspector were invited by a service user to join them for lunch. This was a relaxed and unrushed affair. There was lots of discussions and banter around the table and was a very enjoyable experience. There was an ample choice of healthy food available at lunch and was tasty and very well presented. Service users were observed being supported to prepare lunch and two service users had taken part in the weekly food-shopping trip on the morning of the inspection. Meals are offered three times a day and service users have access to snacks and drinks throughout the day. A record is kept of all meals provided. Service users are weighed regularly and this is recorded in their care plans. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are outlined within their individual plans, ensuring that the manner in which they are supported and cared for by staff is appropriate and promotes their preferences. Healthcare support for service users is good ensuring service users health and wellbeing is promoted and protected. Medication procedures within the home are robust and staff training good, which ensures that service users are protected by the systems in place. . EVIDENCE: Information regarding personal care is recorded in the individual care plans. Service users are very independent and choose when they like to go to bed, have a bath, have their meals and take part in other activities. Care plans set out in detail the service users preferred routines, likes and dislikes and partnerships with families and friends. Staff ensure that personal care is flexible, consistent and responsive to the changing needs of service users. This is well documented in care plans. The staff group is balanced to ensure choice of male, female and age related preferences when delivering personal care. Service users spoken to confirmed Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 15 that their privacy and dignity are always maintained when personal support is provided. Each service user has their own health care file. This records evidence of regular and thorough healthcare screening. Three separate dental services are used by the home. These are local services and are accessed on average six monthly. Chiropody services are based at the local hospital out patients department and optical screening is via a local optician. These are both accessed on a needs only basis. Service users are able to choose their own GP and have access to all NHS healthcare facilities in the local community. Additional support is accessed through a team of healthcare professionals where service users can access physiotherapists, occupational therapists, speech therapists, and community dietician and continence advisor. Visits to the home from healthcare professionals take place in the service users bedrooms. Staff provide support to individuals needing to attend outpatient and other appointments. The service users at the home do not self-administer their own medication. There is an efficient medication policy supported by procedures and protocols. Following the previous inspection a requirement was issued that practices are reviewed for PRN medications and that amendments are made to the procedure in place for the witnessing of medications administered. It is pleasing to see that this has been complied with. The home uses a monitored dosage system. Medication records seen are fully completed with no omissions noted. There were no out of date medications held in the service users home with a returns procedure in place. There are no controlled drugs in use at the time of the visit. Training records demonstrate that staff have undertaken accredited training in the safe handling of medicines. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has effective complaints procedures to ensure that service users or their representatives are listened to. Vulnerable adults are protected through a range of policies and procedures and well-informed staff, which means that their intrinsic human rights are protected. EVIDENCE: Following the previous inspection it was identified that some concerns and complaints expressed by service users had not been explored or addressed. A requirement was issued for all concerns and complaints to be addressed appropriately and that service users have access to the complaints procedures. The home has not received any further complaints since the previous inspection. However the home manager said that all complaints will be responded appropriately and within the stated timescales. It is pleasing to set that all service users have all been given an individual folder that contains the homes Statement of Purpose, Service Users Guide and a copy of the Organisations Complaint procedure. There is a complaints procedure and this informs the complainant who to approach with their complaint. CSCI has not received any complaints about this home. The home use the Milton Keynes Multi Agency “Protecting Vulnerable Adults from Abuse” policy and an organisational policy in conjunction with this. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 17 This includes guidelines for staff about the responsibilities of the staff, types and signs of abuse and what to do if you suspect abuse. All care staff receive training about Adult Abuse and this forms part of their induction. The homes policies regarding service users money and financial affairs ensure service users access to their money, valuables and safe storage is safe guarded. There is a gifts procedure that provides staff with guidelines about receiving personal gifts from service users. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good, providing service users with an attractive and homely place to live. The overall quality of the furnishings and fittings is good ensuring the safety and comfort of service users. Standards of cleanliness at the home appear to be good meaning that service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. EVIDENCE: 49 Stolford Rise (also called Sheeps Tor) 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 activities and amenities are available. The home consists of a two-storey building. All of the bedrooms are single and each service user has their own, separate, individual lounge area. Personal Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 19 bedrooms and lounges are all lockable and service users choose to use this facility. There is one communal lounge. This is nicely decorated, bright and homely. The kitchen is clean, spacious and well looked after. This is accessible to all service users. The furnishings observed in communal areas are of good quality and suitable for the range of interests and activities preferred by service users. Lighting in communal areas is domestic in character and sufficient to facilitate reading and other activities. The home has a pleasant garden that is maintained by staff and one service user. There are no CCTV cameras in use within the home at the time of the inspection. There are accessible toilets available for service users throughout the home. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The home has an infection control policy and the inspector observed this. Instructions are in place for the washing of soiled linen. There are no outstanding maintenance issues found on the day of inspection that would affect the health and welfare of the service users. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a staff team who are appropriately trained to ensure that service users are cared for by skilled staff at all times. Unresolved staffing issues at the home are preventing service users receiving the support they need to fully meet their individual needs. There are effective recruitment procedures in place to ensure service users are protected from harm. There is a staff training and development programme which ensures staff fulfil the aims of the home and meet the changing needs of service users. EVIDENCE: Staff are aware of the organisations policies and procedures and understand how their work, and that of other staff, promotes the main aims of the home. The manager said this was achievable through staff meetings, and supervision sessions. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 21 In discussions with service users and observation of staff files it is apparent that there remain unresolved staffing issues. This has been brought to the attention of the responsible individual and it is a requirement of the report that they investigate the present unresolved staffing issues to ensure a satisfactory outcome. The inspector requests a copy of this is sent to the Commission for Social Care inspection. There appears to be a high level of staff sickness and on the morning of the inspection two care staff called in sick. With a team of only six staff this is a large percentage of the team. This is an area that needs to be explored further by the manager and the organisation. There were no staff members under the age of eighteen and there are no staff under the age of twenty one left in charge of the home at any time. At the time of the inspection there are two staff members with an NVQ qualification. The inspector requested to look at the recruitment files for staff including the most newly appointed staff. Four files were examined. All staff files looked at contains two references, copies of driving licence, certificates of training and a health check. There is evidence that staff have had a criminal records bureau check before they commence work and all staff are checked against the POVA register. Staff spoken to confirmed the process of recruitment. There is an induction programme in place to ensure that new staff members are familiarised with the organisation and their roles and responsibilities and provides the staff member with a personal development portfolio. This includes fire safety, moving and handling techniques and core skills training. Training records reflect that staff have received mandatory training although these now need to be updated. The Deputy Manager who is responsible for organising the staff training said he is aware of this and has already nominated courses for staff to attend. There is specialist training available for staff, an example of this is Autism training. Staff confirmed that there are regular staff meetings. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has not been consistently managed over the previous few years. However, the newly appointed manager has a good understanding of the areas in which the home need to improve to be able to satisfactorily meet service users needs. Various methods of measuring quality assurance are in place ensuring that the quality standards that apply to service provision are maintained to a prescribed standard and, in relation to service users requirements, are not compromised. There are systems within the home that are used to ensure that service users health, safety and welfare are protected and promoted. EVIDENCE: The present manager was appointed in October 2006. Prior to this she commenced work in the home, in May 2006, as a temporary manager and was Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 23 employed by an agency. Once the home manager has completed her sixmonth probationary period she will apply to register with the Commission. Training undertaken by the manager since she has been in post includes basic food hygiene, first aid, moving and handling and autism training. The home manager said she undertook an induction that took place over two weeks. She is an NVQ assessor and a qualified counsellor in bereavement. Previous experience has been within the criminal justice and probationary service. The home has a complaints procedure in place and a whistle blowing policy, which enable staff and service users to voice concerns and affect the way in which the service is delivered. Following the previous inspection a requirement was issued for the organisation to carry out a quality audit of the whole service and that any shortfalls noted are addressed appropriately. It is pleasing to see that this has been complied with. The organisation complete an annual audit and areas looked at include care plans, health and safety, medication, the physical well being of service users, skill development and leisure, social well being, staff development and training and user focused service delivery. The unit general manager said that the organisation is currently devising a service satisfaction questionnaire for service users and associated people. The inspector was informed that the organisation intends to send this out on an annual basis. The organisation undertakes monthly Reg 26 reports and these were available for inspection. Records were seen for fire safety. Regular fire monitoring is taking place with all requirements of the last Fire Authority inspection actioned. These are comprehensive and up to date. The most recent fire drill was undertaken on 24/11/2006 and the fire risk assessment is dated December 2006. Service reports are in place for PAT testing dated 18/10/06, gas boiler certificate is dated 20/04/06, electrical installation certificate is dated 03/03/06, and there is evidence of monthly health and safety checks. COSHH sheets are up to date and accurate. The inspector looked at Infection Control guidelines that are available for all staff. Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 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 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA32 Regulation 12 Requirement The registered provider is required to ensure that the organisation investigate the present unresolved staffing issues to ensure a satisfactory outcome. The inspector requests a copy of this is sent to the Commission for Social Care inspection. Timescale for action 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. Refer to Standard Good Practice Recommendations Stolford Rise (49) DS0000015082.V322925.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stolford Rise (49) DS0000015082.V322925.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. 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