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

This inspection was carried out on 7th August 2008.

CSCI found this care home to be providing an Good service.

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

4a Archers Way 14/08/07

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 12/03/2009.

CARE HOME ADULTS 18-65 4a Archers Way 4a Archer Way Lane End High Wycombe Buckinghamshire HP14 3DN Lead Inspector Joan Browne Unannounced Inspection 7th August 2008 13:15 4a Archers Way DS0000069271.V368925.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.V368925.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.V368925.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 pearl.rowles@turnstone.org.uk 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 Ltd Mrs Pearl Caroline Rowles Care Home 6 Category(ies) of Learning disability (0) registration, with number of places 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care Home only (PC) to service users of the following gender:Either Whose primary care needs on admission to the home are within the following category: 2. Learning Disability (LD) The maximum number of service users who can be accommodated is: 6 14th August 2007 Date of last inspection Brief Description of the Service: The home is registered to provide twenty- four-hour care for six people of both sexes with learning and physical disabilities. On the day of the inspection it was providing care for five people. McIntyre Housing Association owns the house 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 offers care to people with diverse special needs. The house is a domestic dwelling that has been adapted to accommodate six people. There are two bedrooms on the ground floor (one is shared) and three bedrooms on the first floor. However, on the day of the inspection visit one of bedrooms on the first floor was out of use. The first floor is accessed by a staircase and is not accessible to those with poor mobility. Communal accommodation is comfortable and includes a sizeable kitchen and dining area. There is a good size garden at the rear of the premises, which is accessible to some service users. 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. 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 5 It has its own vehicle and some service users are able to access public transport. The current weekly fees are approximately £1,350.13, which includes £187.85 for rent and housing services. 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people who use this service experience good quality outcomes. This unannounced site visit, which forms part of the key inspection to be undertaken by the Commission for Social Care Inspection (CSCI) was undertaken by Joan Browne on 7 August 2008 in the presence of the home manager. A service manager was present for part of the inspection to support the manager. The inspection lasted approximately seven hours commencing at 13:15 pm and concluding at 20:20 pm. The CSCI inspecting for Better Lives (IBL) involves an annual quality assurance assessment (AQAA) to be completed by the service, which includes information from a variety of sources. This document initially helps to prioritise the order of the inspection and identify areas that require more attention during the inspection process. The information contained in this report was gathered from service users’ notes, records kept by the home, a tour of the premises and discussions with support staff. One requirement was made and this can be found at the end of the report in the requirement section with fuller discussion in the text of the report under standard 6. Eight practice recommendations have been made and fuller discussions of these can be found in the text under standards 6, 20, 34 and 42. We (the Commission) would like to thank all the service users and staff who made the visit so productive and pleasant on the day. What the service does well: The home ensures that it is able to meet the needs of the people using the service. Staff support and enable people using the service to make decisions and choices for themselves. People using the service are supported and encouraged to keep in contact with family members. The staff team support and encourage people using the service to take part in activities appropriate to their age and culture inside and outside the home. 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 7 The home ensures that people using the service are supported with their health and personal care needs in the way they prefer. The home has policies and procedures in place to ensure that people using the service are protected from any potential harm or abuse. The staff respect people using the service and are knowledgeable of their disabilities and specific conditions. What has improved since the last inspection? What they could do better: Ensure that there is a supporting plan in place for the person using the service whose behaviour can be perceived as self-harming so that staff can support and promote their welfare. Ensure that care plans are reviewed and updated at least every six months to reflect people using the service changing needs. Ensure that changes to when required (PRN) medication are clearly recorded on the MAR sheet to prevent any errors occurring. Ensure that a risk assessment is carried out on plastic gloves and aprons for the risk they present to the people using the service and action taken to minimise any identified risk. 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 8 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.V368925.R01.S.doc Version 5.2 Page 9 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.V368925.R01.S.doc Version 5.2 Page 10 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. There is a system in place to ensure that prospective people to use the service needs are assessed prior to admission. EVIDENCE: At the last inspection a requirement was made for the home to produce a service user’s guide. It is pleasing to report that the home has developed a service user’s guide in a pictorial format to meet service users’ needs. Since the last inspection the home has not had any new admissions. There is an assessment tool in place. The manager explained the home’s assessment process and said that no service user would be admitted to the home without having had his or her needs assessed. Prospective service users would be expected to visit the home and spend sometime. A trial period would also be offered to ensure compatibility with others living in the home. 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 11 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 &9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service Risk assessments to ensure that service users have an independent lifestyle have been developed. All the care plans have not been completed on the new format, which could mean that all staff may not know individuals’ needs and preferences. EVIDENCE: Three care plans were examined. They were written in a person centred manner, clear and easy to read. Wherever possible, the plans were signed by service users and the staff member involved in the development of the plan. Additional records such as activity and my diary were being maintained daily. It was noted that the care plan for a particular service user did not set out how staff should be supporting the individual’s behaviour, which could be perceived as causing self- harm. This was discussed with the manager during the inspection. A requirement is made for a supporting plan to be put in place detailing the action to be taken by staff to support and promote the individual’s health and welfare. 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 12 Evidence was seen to indicate that yearly reviews of service users’ care needs were taking place involving professionals, relatives, and staff members. We noted that care plans were not reviewed regularly. It is recommended that care plans are reviewed at least every six months and updated to reflect changing needs and any agreed changes should be recorded and actioned. It was disappointing to note that all the care plans had not been completed on the new format. The manager said that she was working with staff to complete this process. Training in care planning had been provided to staff to enable them to be confident and competent with the new documentation. The annual quality assurance assessment (AQAA) reflected that service users were being encouraged to be involved in menu planning, household tasks, shopping and cooking. Evidence of service users’ involvement in daily living tasks was seen in their personal diaries. Staff spoken to were able to demonstrate how they empowered service users to make choices. For example, service users are shown pictures of food and they point to what they wish to eat. We noted that an advocate from a group called ‘talkback’ was supporting all service users and was attending the monthly service users’ meetings. All monies belonging to service users are stored in a cash tin in a lockable storage cupboard in their bedrooms. This is supported with a detailed money risk assessment outlining the level of support that staff were providing to individuals. Risk assessments relating to activities outside and inside the home such as, household chores, use of the hoist, personal care provided by staff, use of bedrails and the use of transport were seen in the care documentation for the service users whose care was case tracked. 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 13 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 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that people are able to participate in activities to meet their diverse needs. Their dignity and rights are respected in their daily life. EVIDENCE: None of the service users living in the home were able to take up opportunities for paid, supported or voluntary work. However, one service user was attending the local college two days a week. Staff commented that the individual’s communication skills and self-confidence had improved. The annual quality assurance assessment (AQAA) reflected that service users were involved in a pilot project as part of the local council modernisation of day care services. This mean that service users receive day care services in their own home twice a week and attend the day centre on the other days. They are provided with activities indoors or outside of the home. On the day of the inspection visit service users had been out on an activity, which they appeared to have enjoyed. 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 14 The home has its own vehicle to transport service users. Some service users are registered with dial a ride and some have taxi tokens. We were told that an extra staff member works during the day at weekends to ensure people have the opportunity to go out if they wish. Staff spoken to during the inspection said that service users were supported to maintain links with family members. Staff escort one service user every weekend to spend time with a family member. Relatives and friends are encouraged to visit at anytime and are made to feel welcome. Staff encourage service users to participate in the home’s daily routine and to visit the local shops. The annual quality assurance assessment (AQAA) stated that ‘staff were expected to knock on the front door when coming on shift and wait for a service user to answer the door.’ Staff respect service users’ privacy by knocking on their bedroom doors and wait for a reply before entering. We were told that service users had been issued with keys for their bedrooms and the front door and they are encouraged and supported by staff to use them when entering the house. The AQAA reflected that service users were supported to purchase a green house and the staff team were supporting them to grow their own vegetables. We observed tomatoes growing in the green house. Staff were observed preparing the meal at teatime. Service users were given the opportunity to participate in the preparation of the meal but declined. We were told that staff had discussed the menu choice with service users the day before. Choices on offer were mincemeat in a curry sauce with chickpeas, rice, potatoes, beef and vegetables. Staff members supported service users with their meal. Some needed to have their meals liquidised which was presented in an attractive manner. Those requiring assistance were assisted by staff in a sensitive, unrushed and discrete manner. Staff were aware of people’s preferences and were able to interpret individuals’ behaviour for example, requiring more food and when one person wanted to eat later. The home’s staff were able to demonstrate how they support individuals to maintain and develop their culture. For example, special dietary needs were catered for and one particular service user had their own cutlery and crockery that was not used by other people. 4a Archers Way DS0000069271.V368925.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 & 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has a system in place to ensure that people receive support with their personal and health care needs in the way they prefer and is sensitive to their race, age, and disability. EVIDENCE: Care plans seen contained information on individuals’ likes and dislikes. And when they wish to rise and retire and to be supported with their personal care. Each person has a ‘communication dictionary’ to assist staff to communicate effectively with them. Service users seemed appropriately dressed with attention to detail. Whenever possible there is a choice of staff that work with them, such as staff from the same ethnic or cultural back ground or the same gender. This ensures consistency and continuity of care. Technical aids and equipment were provided to promote independence. 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 16 All service users are registered with a general practitioner and have access to the national health service (NHS) health care facilities. They have regular chiropody treatment, dental and other medical checks. The home uses a monitored dose medication system. Whenever possible medication is administered by two staff members. The medication administration record (MAR) sheets for three service users were examined and there were no unexplained gaps. However, on one particular MAR sheet there was a scribbled over entry recorded. As a good practice entries recorded in error should state the reason for the error. A recommendation is made in this report to ensure that there is a written explanation on the MAR sheet for entries recorded in error. To comply with best practice guidelines a further recommendation is being made to ensure that the home retain a list of staff members authorised to give medication, which includes a record of their approved initials. We were told that there were no service users with the capacity to self-medicate. Medication was stored in individuals’ bedrooms in a locked cupboard. On the day of the site visit there were no service users prescribed for controlled medication. The home has a system in place for the return and disposal of medication. Guidelines for medication to be given when required and how it should be given and how to detect when individuals were in pain were in place. However, staff need to make sure that changes to when required (PRN) medication are clearly recorded on the MAR sheet to prevent any errors occurring. The annual quality assurance assessment (AQAA) stated that ‘staff members who administer medication attend the care and control medication training and complete a practical and theory assessment.’ The manager said that she regularly assesses staff’s competence and evidence of a staff assessment was seen. 4a Archers Way DS0000069271.V368925.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 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has a complaints procedure in place to ensure that people using the service or their representative are able to express their concerns and action taken to put things right. Staff have had training in the safeguarding of vulnerable adults which should ensure that they aware of how to protect people from any potential risk of harm or abuse. EVIDENCE: The home has a complaints procedure, which has been produced in a userfriendly format. The annual quality assurance assessment (AQAA) reflected that the home had received one complaint since the last inspection, which was investigated and upheld. A record is maintained for complaints received. No complainant had contacted the Commission with information concerning a complaint made to the service. The home has procedures in place for responding to suspicion or evidence of abuse or neglect to ensure service users’ safety and protection. The home’s AQAA indicated that it has had two safeguarding of vulnerable adults referrals made within the last twelve months. The Commission was aware of one of the referrals that had been made. We were told that staff have had updated training in the safeguarding of vulnerable adults. Staff spoken to on the day of the inspection were aware of the action that should be taken if they witnessed or suspected any incident of abuse to service users. 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 18 Service users are supported by staff with their finances. Each service user has a money risk assessment in place. Written records of all transactions are maintained and money for individuals is kept in a locked tin, stored in a locked drawer in their bedrooms. The manager stated that during a routine auditing of service users’ money an error in a particular service user’s transaction details was detected and she had started an investigation into the anomaly. 4a Archers Way DS0000069271.V368925.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 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Although people live in a home that is clean and hygienic the lay out and size of the home does not fully promote their diverse needs. EVIDENCE: The home is a domestic dwelling situated on two floors. There are two ramps to accommodate wheelchairs at the front and back of the building. There are two bedrooms on the ground floor and one is shared. Three bedrooms are situated on the first floor. However one of the bedrooms has been out of use because of its limited space. The first floor is accessed by a staircase and is not accessible to those with poor mobility. There is a bathroom and toilet on the first floor and a shower area and toilet on the ground floor. There is a lounge area and a kitchen and dining area situated on the ground floor. Currently, none of the bedrooms meet the required standard, However, the service is in the process of moving to a new purpose built home. The staff have worked hard to ensure that the current bedrooms are comfortable and pleasant for service users. 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 20 The fire and safety officer has inspected the home and all matters relating to fire safety appear to have been addressed. The bedrooms and bathrooms’ issues are to be addressed at the reprovisioning of the service and have been agreed with the Commission. On the day of the inspection the home was clean, tidy, hygienic and free from offensive odours. The laundry facility was being appropriately maintained. The home has policies and procedures for the control of infection including safe handling and disposal of clinical waste. 4a Archers Way DS0000069271.V368925.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 & 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The staffing levels in the home were satisfactory to ensure that people are supported by a staff team that recognises and responds appropriately to their diverse needs. EVIDENCE: The annual quality assurance assessment (AQAA) reflected that the home employs six full time staff members and five part -time staff members. The home has not employed any new staff members since the last key inspection. The manager said that rotas were developed to meet service users’ needs. The rota cover aims to provide two staff on the morning shift and four on the afternoon/evening shift, and two waking night staff. On the day of the inspection three staff were covering the afternoon/evening shift. A staff member who responded to the Commission’s survey was concern that the home had introduced a new rota, which does not allow time for a handover. The concern was referred back to the manager to be addressed. The manager said that shortfalls in staffing numbers were covered by agency and bank staff. The service requests the same agency staff to ensure continuity of care. 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 22 We noted that four staff had achieved the national vocational qualification (NVQ) in direct care in level 2. The service ensures that regular staff meetings are held and staff forums take place every three months. Permanent and agency staff spoken to said that they receive regular recorded supervision at least every six weeks. The manager said that the organisation provides statutory training updates and other training courses such as communication training and value based practice training. A staff member who responded to the Commission’s survey commented that it would be useful ‘to have training in how to deal with challenging behaviour and with people who are autistic.’ These comments were passed on to the manager to be considered. Staff spoken to during the site visit said that they were provided with regular training updates which should ensure that service users are looked after by staff who have been appropriately trained to meet their complex and diverse needs. The home has not appointed any new staff members since the last key inspection. Staff records seen indicated that all the necessary documentation was in place to ensure that service users are looked after by staff that have been appropriately recruited. We observed that information on some agency staff was not detailed. The details of staff’s criminal record bureau clearances were confirmed. However, information such as, mandatory training undertaken by staff members was not disclosed to the home. This was discussed with the manager and the service manager during the inspection. We noted that some agency information sheets had information relating to more than one staff member. This practice should be reviewed to ensure that confidentiality and data protection is not breached. We observed staff interacting with service users in a kind and respectful manner. Staff were knowledgeable on the disabilities and specific conditions of service users and looked comfortable in their company. 4a Archers Way DS0000069271.V368925.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 & 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has systems in place to ensure that people using the service safety is promoted. EVIDENCE: The manager has acquired the national vocational qualification (NVQ) in level 3 and 4 as well as the registered manager’s award. She undertakes periodic training to update her knowledge skills. She also attends joint manager’s meetings and management workshops. Staff spoken to said that the manager was approachable and communicated a clear sense of direction relating to the aims and purpose of the home. The home has a quality assurance system in place. Feedback is sought from service users, staff and relatives and responses received are included into the 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 24 home’s continuous improvement plan. Regular staff forums are held and practice issues are discussed. Evidence was seen indicating that monthly regulation 26 visits were being carried out. Poor practice issues are highlighted and the manager is expected to develop an action plan to address the issues. A sample of health and safety records and accident and incident forms was seen, which was completed regularly and satisfactory. We observed that regular fire drills were taking place. To comply with best practice guidelines it is recommended that the names of staff members participating in fire drills should be recorded. Plastic gloves and aprons were seen to be stored in toilets and it is recommended that the home carries out a risk assessment for the risk they present to the people that use the service and action taken to minimise any identified risk. 4a Archers Way DS0000069271.V368925.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 3 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 3 23 3 ENVIRONMENT Standard No Score 24 2 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 3 3 X 3 X 3 X X 3 X 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 12(1) Requirement The service user whose behaviour could be perceived as self-harming must have a supporting plan in place detailing how staff should support and promote their welfare. Timescale for action 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA6 YA20 Good Practice Recommendations All care plans should be completed on the new format to ensure that all staff are aware of service users’ needs and preferences. To comply with best practice guidelines the home should ensure that care plans are reviewed and updated at least every six months to reflect individuals’ changing needs. To comply with best practice guidelines the home should ensure that scribbled over entries are not recorded on the medication administration record (MAR) sheets. Entries recorded in error should have an explanation. To comply with best practice the home should retain a list of staff members authorised to give medication including a record of their approved initials. DS0000069271.V368925.R01.S.doc Version 5.2 Page 27 4 YA20 4a Archers Way 5 6 YA20 YA34 7 YA34 8 YA42 Changes to when required (PRN) medication should be clearly recorded on the MAR sheet to prevent any errors occurring. The home should discuss with the agency how information on agency staff members is recorded and forwarded to the home to ensure that confidentiality and data protection is not breached. The home should make sure that the agency discloses what mandatory updated training agency staff have undertaken. This would ensure that staff whose knowledge and skills are regularly updated looks after service users. A risk assessment should be carried out on plastic gloves and aprons for the risk they present to the people that use the service and action taken to minimise any identified risk. 4a Archers Way DS0000069271.V368925.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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