Inspection on 14/08/07 for 4a Archers Way

This inspection was carried out on 14th August 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4a Archers Way 07/08/08

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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 4a Archers Way 4a Archer Way Lane End High Wycombe Buckinghamshire HP14 3DN Lead Inspector Kerry Kingston Unannounced Inspection 14th August 2007 10:30 4a Archers Way DS0000069271.V344529.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 4a Archers Way DS0000069271.V344529.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. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 4a Archers Way Address 4a Archer Way Lane End High Wycombe Buckinghamshire HP14 3DN 01753 747372 01494 883528 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) Turnstone Support Limited Care Home 6 Category(ies) of Learning disability (0) registration, with number of places 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New service. Brief Description of the Service: The home provides twenty- four hour care for six people of both sexes with learning and associated physical disabilities. The house is owned by McIntyre Housing Association and the care is provided by Turnstone Support. The service has been in existence for many years but was registered in March 2007 when it was transferred from the Health Authority to Turnstone Support, a private provider who offer care to people with diverse special needs. The house is a domestic dwelling that has been adapted into accommodation for six people, there are two bedrooms on the ground floor (one is shared) and three bedrooms on the first floor. The first floor is accessed by a staircase and is not accessible to those with physical disabilities or frailties. Communal accommodation is comfortable and includes a sizeable kitchen and dining area. There is a good size rear garden, which is accessible to those with physical difficulties. There are limited bathing and toileting facilities, for those people with physical disabilities. The home is approximately three miles from the town centre and there are local facilities within walking distance. The home has its own vehicle and residents are able to access public transport. The fees are £1,317.20 per week, which includes £179.94 for rent and housing services. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report for the first key inspection of the service, which included a routine unannounced site visit. This took place between the hours of 10.30am and 6.30pm on the 14th August 2007. The information was collected from an Annual Quality Assurance Assessment, a document sent to the home from the Commission for Social Care Inspection and completed by the manager, surveys which were sent to people who use the service, other professionals and families of residents. Two surveys were returned to the Commission, one from another professional and one from a family member. Discussions with one staff member, the team leader and the Regional Manager (Responsible Individual) took place. The people who use the service are not able to verbally communicate and have communication systems learnt by staff over a period of time, people and their interactions with staff were observed during the times that they were present. A tour of the home and reviewing residents and other records was also used to collect information on the day of the visit. The home transferred from the Health Authority to Turnstone Support in March 2007 and the home is continuing with transitional and development work created by the transfer. The home is part of a re-provisioning project due for completion at the end of January 2009. All areas of care, with particular regard to the care plans and record keeping is under development, with development goals and plans in place, these are being generally adhered to. What the service does well: The home makes sure that they are able to meet the needs of the people who live there. The staff help people to make decisions and choices for themselves. The home tries to make sure that people have plenty of things to do so that they enjoy their life and do not get bored, they do much more around the home. People are helped to keep in contact with their families and people who are important to them. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 6 The home makes sure that people are properly treated and protected. The staff work hard to make sure that the house is as comfortable and clean as is possible. Staff are given training so that they know how to meet the needs of the residents in the best way possible. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 4a Archers Way DS0000069271.V344529.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 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5. People who use the service experience adequate quality outcomes in this area. The home has produced an up-to-date Statement of Purpose but residents do not have a Service Users Guide to tell them what they can expect from their care and how much it costs. Residents have a recent assessment so that the home is sure that it is able to meet their needs. They are involved in making choices and decisions, as far as is possible about their future accommodation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an updated Statement of Purpose but this has not yet been provided in pictorial form or a user- friendly format for individuals, the Regional Manager advised that this work has been completed. A Service Users Guide is in the process of being completed and will incorporate a service agreement/contract, which includes the costs of care, a housing and housing services licence agreement is already in place. People did not choose to live in the home but have been resident for some years and are being kept informed, as far as possible about new homes to be provided due to the re-provisioning project. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 9 All residents were re-assessed by the present providers in February 2007 prior to transfer and have since had their assessments reviewed. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People who use the service experience good quality outcomes in this area. Each person has an individual care plan to ensure that staff know how to support them. Good progress is being made on the new care plan formats that when completed will enhance the information provided to inform everyone about the needs and preferences of the residents. Risk assessments are completed to ensure that residents can remain as independent as possible but some are missing with regard to practical issues, such as the use of ‘cot sides’. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans for four people were seen. Much of the new paperwork is in evidence but it is not all completed, the home is prioritising their work for completion of the care plans and are meeting the time schedules set in the improvement plan. Staff are using existing care plans where the new formats have not been completed and these enable them to fulfil the day-to-day tasks to meet the needs of the residents. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 11 A Key worker is identified for each resident, they have specific duties and responsibilities that are detailed in a Key working policy/procedure. Peoples’ diverse needs are addressed in their individual plans, but the issues of culture and belief systems are not detailed on the new care plan format although they are clearly identified on the assessment paperwork. There is evidence that residents are being encouraged to become more involved in the day to day running of the home, such as peoples’ food choices and how they make their choices are noted on the menu (all residents are non-verbal and have complex communication systems). An advocate from a group called ‘talkback’ visits every two weeks and information is being discussed with people such as ‘keeping information about me’, ‘holding spare keys’ and ‘Medication administration’ staff sign documents to confirm that issues have been discussed with residents even though they may not be able to fully comprehend the information given. Residents meetings are held monthly and most residents attend. These have been held regularly since registration in March 2007, they generally have good content including the passing on of information and listening to peoples’ views and ideas. The content of the meetings is continuing to improve. New care plans note residents finances and who manages them but not all individuals’ finances are clear, as transfers of monies has not been fully completed. Risk assessments are in place, they were completed in July 2007. They include household chores, use of transport and community presence, but the use of ‘cot sides’ has not been risk assessed and bathing assessments for those who want total privacy may need to be more detailed, as discussed with the Team Leader. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. People who use the service experience good quality outcomes in this area. People have regular daily, planned activities. Informal activities during the evenings are limited by residents being tired but the home is trying to ensure that there are more weekend activities and holidays are to be planned. People are increasingly involved in the daily routines of the home, which include shopping for food and other essentials. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents go to external day services, four people have formal, organised day services for five days per week and one person attends day services for four days per week. Day services are between 9.00 am until after 4 pm every day. Two different day services are used, depending on who can offer the most appropriate day programme for individuals. The home has a record of activities provided by the day centres and help residents to choose their activity programmes. The Day centres assess each person’s needs individually 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 13 and offer a varied programme to those who use the service. People are often quite tired on return from day activities as they have to get up quite early to ensure they are ready on time for the transport, one report noted that a resident was offered an evening activity but chose not to participate as they were too tired. During the visit some people were observed to be tired and in need of a rest, just after the main meal. Records showed that weekend activities such as a picnic, a visit to the park and shopping trips had taken place during the first two weekends of August 2007. People did not have an annual holiday in 2006 and so far, have not been on holiday this year. The Team Leader said that holidays are to be booked for 2008 with the possibility that there could be some planned later this year. The home has its own vehicle and public transport is available, one resident was seen to use public transport for trips to the community with staff members. The home keeps good activity records, including day activities, but some could include more detail, particularly if residents decline activity opportunities during the evening or at weekends. An extra staff member works during the day at weekends to ensure people have the opportunity to go out, if they wish. A survey received from family members noted that ‘communication with families is very good’. Two of the people who live in the home have no contact with families although the home continues to try to keep in contact, they are considering individual advocates or befrienders for the residents but have had no success with identifying anyone, at this time. The other three residents have regular contact with families and this is supported and encouraged by the staff team. Staff discussed how they ensure that people are able to make choices for themselves such as residents now go shopping although it takes a lot longer; staff do not enter peoples’ bedrooms without them being there and they get much more choice of what to eat. Senior staff are trying to ensure that people have enough personal allowance to enable them to be taken to choose their own clothing rather than it be bought for them and to enable them to access community activities, such as meals out. Individuals have a ‘communication dictionary’ to assist staff to interpret peoples’ complex communication methods. Staff were observed asking people what they wanted to do, offering choices and responding to peoples’ communication methods. The menu offered good quality balanced food, there were three choices on the menu and a description of how people chose the meal they wanted. Observation of the mealtime showed that staff assisted those people who needed help with their meal, sensitively and effectively. Staff knew peoples’ likes and dislikes and were able to clearly interpret behaviour at the table, 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 14 such as one person wanting more food, when one had had enough food and when one person was tired and wished to go to rest on her bed, before completing the meal. One person did not wish to eat at the mealtime and was able to eat later or have alternative food. People have weight and food and drink diaries but these are not completed on a regular basis. There was a major variance between the advice/guidelines written by a speech and language therapist and the feeding guidelines written in the individuals’ care plan. The issue of health guidelines and records being consistent and properly completed was discussed with the Team Leader and Regional Manager who agreed to address it immediately. (See Personal and Healthcare Support.) 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use the service experience adequate quality outcomes in this area. The home meets the personal needs of the people who live there. The systems for ensuring that all their health care needs are met are not as robust as they should be because some advice given by other professionals is not transferred to care plans and not known by residential staff. Communication between the day centre and the home with regard to health issues is not always good enough to ensure peoples’ safety. Medication is, generally, administered safely but guidelines for medication used as necessary are not as detailed and consistent as they should be. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans include information about peoples’ likes/dislikes and preferences, the detail of this will be improved when the new care plan formats have been completed. Care plans also note that people choose when to get up and go to bed and how they express these choices, a ‘communication dictionary’ helps staff and others to understand peoples’ varying and individual communication systems. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 16 Healthcare notes are kept but a substantial number of health records were archived in March and there have been limited records kept since, new health care plans and recording formats are not completed, at this time. The senior staff member advised that not all the residents have had an annual medical/medication review, this has been identified at reviews and they are being organised All residents have a key worker allocated and offer same gender personal care whenever possible, the home has a cross gender care policy and are very aware of peoples’ dignity and privacy. People are supported to attend church and their religious cultural needs are noted on their individual assessments. There is limited detail of cultural/religious needs on individual care plans but they include detailed information with regard to equality and diversity issues, such as physical needs, sensory needs and emotional needs. The home does not have individual guidelines for any behaviours that cause residents difficulties, such as one person biting themselves and another being medicated for behaviour that is not noted on care plans. Eating/drinking/feeding guidelines supplied by speech therapists after assessments in July 2007 do not correspond with care plan risk assessments or guidelines. Other charts, such as weight, bowel and food and drink diaries are not, consistently, completed. Medication for one person is kept in a locked metal cabinet in the dining area and the other four people have medication in their bedrooms in locked cupboards. Medication is administered by two people, whenever possible, the Boots Monitored Dosage System is used. The pharmacist does not visit but is always available on the phone and is very helpful. The medication administration records for three residents were seen, they were accurate and properly recorded. Staff have to have received training and be assessed as competent by the manager before they can administer medication. Some guidelines for medication to be given when required, describe when and how to give them and how people indicate when they are in pain, the guidelines are signed by the GP. Some of the protocols/guidelines for the administration of medication prescribed, as required such as rectal diazepam are not as clear and are different at the day centre. The day centre do not send written reports when they have administered rectal medication or when people have had seizures, they pass this information to residential staff via the telephone. This practice was discussed with the Team Leader and the Regional Manager who agreed to review it immediately. There is a comprehensive medication policy and procedure, which includes reviewing whether people can administer their own medication independently. People are unable to administer medication independently. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. The home protects people from all forms of abuse and has a robust complaints procedure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a robust complaints procedure, which has been produced in user - friendly format, this includes pictures, symbols, tape and D.V.D. There have been no complaints since registration in March 2007. One survey received from family members noted that they knew how to make a complaint but this had not been necessary. There have been no safeguarding adults incidents since March 2007. Staff have received (or it has been booked) Protection of Vulnerable Adults training and others are currently embarking on refresher courses. One staff member described what they would do if they were concerned about abuse. The Commission has received no information with regard to complaints or safeguarding adults issues about the home. The manager advised that the home does not use any form of physical restraint. The financial affairs of the service users have not been completely resolved, as yet. There are to be several systems, some having family members as appointees, others are to have the local authority acting as receivers on behalf 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 18 of the court of protection, therefore being appointees for individuals. It is not clear how residents will be made aware of their overall financial situation, including their income and expenditure when all the financial arrangements have been resolved. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25 and 30. People who use the service experience adequate quality outcomes in this area. That the home provides a good environment for the residents to live in and it is clean and hygienic. The environment is improving with new furniture, equipment and decorating completed. Two bedrooms remain inadequate but plans to address this problem, as agreed at registration, remain on schedule. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is extremely clean, tidy and comfortable. There is new sitting room furniture, communal areas and some bedrooms have been newly decorated and external painting and fence repairs/replacements have been completed. Those people who need it have their own specialised chairs and the downstairs shower room has all the necessary aids to ensure people can access the facilities safely. One person has a new shower chair to make her personal care more comfortable. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 20 Those people with physical needs are not able to bath but their diverse needs are catered for as much as is possible. Two people share a small double room, a curtain is provided for privacy and the resident who needs attention during the night does not wake the other person who shares the room. New wardrobes and cupboards have been provided, in the room, to maximise space for the residents. Another bedroom is very small but the resident indicated that she liked her room and spent some time in there during the course of the visit. Staff have made the room as pleasant as possible, a new wardrobe has been provided and other storage furniture is kept in the hallway area. The bedrooms and bathroom issues are to be addressed at the re-provisioning of the service and have been agreed with the Commission. Bathrooms have proper waste disposal bins and use a yellow bag system to dispose of ‘infected waste’. The staff have worked hard to ensure the house is as comfortable and pleasant an environment as is possible, within limited resources. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. People who use the service experience good quality outcomes in this area. The home has a team of staff who are competent, well trained and able to meet the needs of people who live there. The home tries to ensure that temporary staff are skilled and properly trained and are as consistent as possible, to minimise the negative effect that may result from long term shortages of permanent staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has seven day staff and four night staff, there are two staff on the morning shift and three on the afternoon/evening shift, there are two waking night staff. At the weekend an extra staff member is employed from approximately 10 am to ensure people can access activities. The home has 4.5 vacancies because of long standing recruitment difficulties and the previous provider not recruiting for 18 months prior to transfer. Shortfalls in staff are covered by agency and bank staff. Inconsistencies of care are minimised by using the same bank and agency staff wherever possible. Two surveys noted that temporary staff may not know the needs of the people who use the service. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 22 The home ensure that they have a training profile for all agency staff so that they know that the temporary staff members have the requisite skills and knowledge, there is also a comprehensive induction for temporary staff to ensure that, as far as possible, they are aware of the needs of individuals. Five of the eleven staff members have NVQ 2 or above qualifications and one staff member has been nominated for NVQ 3. The organisation has a training calendar that covers statutory and other courses and encourages staff to apply for professional training. Staff are supervised every four to six weeks and all have a training record and training profile, which evidence ‘ongoing’ training. Staff confirmed that there are good training opportunities, although one person said that it was often distant from the work place. Two staff records were seen, they included all the necessary documentation to ensure the safety of workers. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. People who use the service experience adequate quality outcomes in this area. The home is well managed and the manager has applied for registration with the Commission for Social Care Inspection. A quality assurance system is in place and will be fully operational, as appropriate. The home, generally has a good standard of Health and Safety but action is not always taken to minimise the risk of incidents/accidents from recurring. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current manager is not yet registered, she has applied for registration. She completed a registered managers award in February 2007 and has had 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 24 managerial experience at team leader level, there was evidence of completion of several specific management training courses. The manager was not available on the day of the inspection visit, the Team Leader and Regional Manager were available throughout the inspection visit. The Team Leader has been in post since June 2007, she displayed sound knowledge of individuals’ needs and the management of the home. Quality Assurance systems are being used, the resident’s views are currently being sought and feedback is due by the 12th September 2007. Staff feedback will be sought in January 2008. An annual report is completed from the responses received from carers, relatives, residents and staff and a ‘continuous improvement plan’ is then formulated, to ensure that Quality is maintained and enhanced. Re- provisioning plans are still ‘on target’ and the home is trying to keep residents as involved and informed as is possible. Quality Assurance includes the formal monitoring of complaints and concerns, monthly Regulation 26 visits, a staff forum that meets quarterly, ‘ad hoc’ visits to the home to focus on specific areas of practice and ‘spot checks’ that are sometimes done during the night. A sample of Health and safety records was seen, all are completed regularly and satisfactorily. Safety certificates were issued prior to registration and are still valid. The organisation has a Health and Safety Officer who is able to give specialist advice to the home, as required. The home has safe working practice risk assessments and completes a monthly health and safety checklist. The home has registered with the local environmental health agency as a ‘food premises’. The home uses accident and incidents forms and serious ones are sent to the Health and Safety officer for monitoring. Some accident and incidents forms, such as one describing bruising to a resident, do not always have full comments by the manager with regard to what will be done to investigate incidents and/or to minimise the risk of recurrence. This Regional Manager agreed that this would be addressed immediately. Risk assessments for ‘cot sides’ are also necessary. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 2 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 2 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 2 3 X 2 X 3 X X 2 X 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 26 New Service Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement To provide the people who use the service with a Service Users Guide that includes a Statement of Terms and conditions, so that they know what to expect from the care they receive and the costs of that care. To develop Healthcare plans that clearly show healthcare needs and appointments made to meet those needs. They must be of a quality to enable staff to monitor peoples’ health and address any health issues promptly. To include emotional health, including behavioural guidelines, in the care planning process to ensure that any issues, which cause the people who use the service distress, are dealt with as effectively, as possible. To ensure that any guidelines developed by healthcare specialists are followed by residential staff, so that residents receive the best possible care to safeguard their health and well being. 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 27 Timescale for action 01/10/07 2. YA19 12 (1) 01/10/07 3 YA42 13 (4) To provide all the necessary risk assessments (particularly the use of cot sides) so that the people who use the service are kept as safe as possible. To complete accident/incident forms so that the actions taken to investigate and minimise the risk of recurrence is clear to ensure that the people who use the service are protected from risks, as far as possible. 01/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA19 Good Practice Recommendations To ensure that the residential service receives a written report from the day service of any incidence of them administering medication prescribed ‘as necessary’, and any incidence of seizures or other significant health events. This will make sure everyone knows what has happened and what medication has been administered, so that the home can effectively monitor and safeguard residents’ health. To ensure that medication guidelines and protocols for the administration of medicines prescribed ‘as necessary’ are clear, up-to-date and the same ones are used in day services and the home. To make sure that people know what their overall financial status is, including their income and expenditure so that the manager can assist them to protect themselves from any form of financial abuse and help them to make informed choices with regard to their expenditure. 2. YA20 3. YA23 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House, 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 4a Archers Way DS0000069271.V344529.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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