Inspection on 25/05/06 for 5 St Margaret`s Gardens

This inspection was carried out on 25th May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5 St Margaret`s Gardens 21/05/09

5 St Margaret`s Gardens 24/05/07

5 St Margaret`s Gardens 18/10/05

5 St Margaret`s Gardens 09/05/05

5 St Margaret`s Gardens 20/12/04

5 St Margaret`s Gardens 20/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 St Margaret`s Gardens (5) Melksham Wiltshire SN12 7BT Lead Inspector Malcolm Kippax Key Inspection 25th May 2006 11:50 St Margaret`s Gardens (5) DS0000028372.V289072.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 St Margaret`s Gardens (5) DS0000028372.V289072.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. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Margaret`s Gardens (5) Address Melksham Wiltshire SN12 7BT 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) 01225 709691 Ordinary Life Project Association Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2005 Brief Description of the Service: 5 St Margarets Gardens is one of a number of homes that are run by the Ordinary Life Project Association (OLPA). The home is located in a residential area on the outskirts of Melksham. 5 St Margarets Gardens is a two storey detached house that is in keeping with the neighbouring properties. Each service user has their own bedroom, one of which is on the ground floor and has an en-suite bathroom. The other accommodation includes a lounge, dining room, kitchen, an upstairs bathroom and a separate W.C. There is a large garden at the side of the property. At least one member of staff, or the manager, is working throughout the day. The service users attend day activities in the community. The current fees are in the range of £797.75 - £973.76 per week. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included two visits to the home. One, which was unannounced, took place on 25 May 2006 (between 11.50 am and 4.00 pm) and a second visit, which took place on 5 June 2006 between 3.00 pm and 6.05 pm. Three service users, two staff members and the home’s manager were spoken with during the visits. A fourth service user was also around on 5 June but spent much of their time outside the home. Staff recruitment records were seen on 16 May 2006 at the OLPA office. The relatives of one service user were met with during the visit on 25 May 2005. Comment cards were sent to the close relatives of the other service users and to the service users’ placing authorities. One relative and one local authority care manager returned their comment cards. Other information has been received and taken into account as part of this inspection: • • A pre-inspection questionnaire about the home that was completed by the manager and the OLPA service co-ordinator. Reports and notifications received by the Commission from the home since the last inspection. The judgements contained in this report have been made from evidence gathered during the inspection, including the visits to the home. What the service does well: What has improved since the last inspection? A new kitchen has been finished. Changes in the staff team have reduced the need for agency carers to be used. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 6 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. St Margaret`s Gardens (5) DS0000028372.V289072.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 St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Standard 2 did not apply at this time. There were no vacancies and there have been no changes in occupancy since the last inspection. (Standard 2 was inspected and met at the last inspection in October 2005). EVIDENCE: St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before and during the visits to the home. Service users are asked about their personal goals and new things that they would like to do. There are records that provide good information for staff and help in the monitoring of the service users’ progress. The service users’ care needs, and how staff provide support with these, are not well reflected in the records. This may result in inconsistencies in the support they receive. Service users are encouraged to be independent and to participate in activities that involve a degree of risk. The service users’ safety may be compromised because of the way in which risks are assessed. EVIDENCE: A meeting took place during the visit on 25 May when a service user’s personal goals and needs for the year ahead were discussed. This was part of a system of ‘Shared Action Planning’. Following the meeting, those present said that it had been a good opportunity to look at the service user’s current needs and to make decisions about what they would now like to do. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 10 Each service user had an individual file that contained their current shared action plans. These included details of personal goals that had been achieved during the last year. Progress with achieving the goals was being recorded by staff as part of a three-monthly review. The manager said that two service users were due to have meetings in June about their new shared action plans. One service user said that he continued to have a part-time job, which he could get to independently. He enjoyed this work, which involved meeting with different people. The manager said that another service user had recently started doing some voluntary work in a local care home for older people. A risk assessment had been undertaken in April 2006 concerning this work. No review date had been identified and it was seen that other assessments were not being reviewed on a regular basis. Overnight stays and cycling had been the subject of risk assessments in 2003. Review dates in 2004 had been identified but it was unclear what the outcome of the assessments had been at that time. The manager said it was intended to undertake assessments in the near future to look at the ability of two service users to spend time alone in the home. In addition to the shared action plans, the service user’s individual files also included a range of guidance for staff about personal support and preferred routines. The content of the files differed, with much of the information included under the headings of ‘unfamiliar guidelines’ and ‘daily routines’. One person had a care plan, which was dated May 2006. The manager said that it was the intention to produce individual plans that would better reflect how service users needed to be supported and provide information for staff in a more co-ordinated way. A file had been produced for agency staff, which included a care plan for one service user. The plan focussed on describing needs, rather than how support should be provided. This included the service user needing to be registered with a dentist. Service users met together at ‘tenants’ meetings. The minutes showed that service users have ideas about what they want to do and make decisions, such as where they would like to go on holiday. The appointment of a new staff member had been discussed at a meeting in April 2006 St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visits to the home. Service users take part in different activities that reflect their interests and individual preferences. Service users are part of the local community, which brings them into contact with people outside the home. Service users benefit from how staff approach their role, which encourages choice and participation. Service users receive support with their relationships. Service users enjoy the meals and are consulted about the menus. EVIDENCE: Service users attended different activities during the week. This included occupation outside the home, such as work placements and attending resource centres. One service user had fewer planned activities and said they were getting back into a more normal routine after a period of rehabilitation following major surgery. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 12 Service users said that they enjoyed their activities outside the home, particularly their part-time jobs. Two service users went out by themselves and one person used a bicycle regularly. A support worker had attended the shared action planning meeting in her role as the service user’s key worker. The role included liaising with close relatives, who had also attended the meeting. Information about family relationships and important contacts was included in the service users’ individual files. Guidelines had been written in April 2006 concerning the contact that a service user has with their parent. One service user had a personal goal as part of shared action planning, that concerned friendship and receiving support with a relationship. Service users spoke about the things they can do in the home. One service user said they made their own breakfast but had support with other meals. Sometimes service users helped staff to prepare the evening meal. Service users said that they feel they can be private in their rooms and that staff knock on the bedroom doors. One service user enjoyed being able to have a pet cat in the home. During the visit on 5 June, a staff member prepared the evening meal, which involved making different dishes that the service users had chosen. Service users were in and out of the kitchen at the time. A record of meals prepared was kept in the service users’ personal diaries. This showed that the service users had often chosen different meals, although the amount of detail varied, which appeared to depend on who had made the record. Service users could have keys to their own rooms but did not have a key to the front door. The manager said that this was to be discussed at a future meeting. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visits to the home. Service users have received the support that they need with their personal and health care. One service user in particular has benefited from the involvement of staff and health professionals during the last year. Service users are protected by the home’s procedures for the safe handling of medication. EVIDENCE: Service users had their own rooms where they could be private in their personal care. One service user had a ground floor room with an en-suite bathroom. There were guidelines in the service users’ records about their daily routines and health care. As reported under Standards 6 – 10, individual plans need to be produced which better reflect all aspects of the service users’ assessed needs and how these are to be met. Support for three service users with personal care was mainly in the form of prompting, rather than ‘hands-on’. When asked about support, service users mentioned practical tasks such as cooking and shopping. One service user said that a chiropodist visits to cut toenails because the staff can’t do this. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 14 Details of appointments with GPs and other healthcare professionals were recorded on forms in the service users’ files. One service user had attended hospital appointments in recent months following major surgery. This was reported to have been successful and the service user’s close relatives felt that there had been good support from the staff team with post-operative care and rehabilitation. A physiotherapist was now involved. The service user had needed to have the operations in another part of the country, which meant that the visiting arrangements were less straightforward than they might have been. In retrospect, the relatives felt that this was something that could have been discussed and arrangements agreed at an earlier stage. In their comment card, one of the service user’s relatives confirmed how pleased they are with the care being provided in the home. Medication was stored safely. Staff members administered the medication, as this was not something that service users were assessed as being able to do themselves. A stock record of medication was being kept and the records of administration were up to date. These were contained in a file that included medication profiles and drug information cards. Drug administration was included as a subject in the OLPA training programme, which is provided ‘in-house’. There was no specialist input into the training that staff receive about medication and drug use. This was recommended at the last inspection but has not been arranged. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visits to the home. Service users are encouraged to raise concerns and they have the information they need about making a complaint. Staff have an awareness of abuse, which helps to protect service users. EVIDENCE: When asked, service users mentioned various people including their key worker who they could talk to if they had a problem with something. Service users had the opportunity to discuss concerns together in the regular ‘tenants’ meetings. OLPA has produced a complaints procedure that includes contact details for different agencies. There was a complaints log in the home. No complaints had been made during the last year. Abuse awareness is included in the OLPA training programme for support workers. The subject is covered in a short statement in the home’s policy and procedure file, which makes reference to ‘No Secrets’ and to a guidance document on the protection of vulnerable adults from abuse in Swindon & Wiltshire. Staff confirmed the training that they had received and that they had been given a copy of the ‘No Secrets’ booklet, which gives guidance about abuse and what to do if abuse is suspected. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate, but improving. This judgement has been made from evidence gathered before and during the visits to the home. The accommodation is meeting the service users’ needs. The home’s location benefits service users and several of their regular activities are within walking distance. The standard of decoration varies within the home; the kitchen has improved although other areas are in need of attention. EVIDENCE: The home is located in a residential area and is close to a main road that goes through Melksham. During the visits, two service users went out locally by themselves. One of the service users walked to a part-time job and another went out cycling. Service users said that they like their own rooms. During the visits, service users spent time in their rooms and also chose to mix with other people in the lounge. The lounge was comfortably furnished and had a television and video St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 17 player. There was a separate dining room, which provided an additional communal space for quieter activities. Laundry was being carried out in the attached garage, which was also used for storage. The laundry area has improved with the removal of an old carpet and the floor has been painted to produce a more washable surface. A previous recommendation about the provision of a hand washing facility has not been met. The accommodation generally was homely and domestic in character. The kitchen has been refurbished during the last year. New units had been fitted and there were new wall tiles. Some additional shelves in the cupboards would be useful. The tiling in the bathroom was in poor condition and there was no shade for the light bulb. The hall carpet was stained in places and the wooden radiator covers in the hall and the lounge needed to have a topcoat of paint. Reports in the home showed that these areas were to be addressed during the coming year. There is a good-sized garden along one side of the home. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before and during the visits to the home. Service users benefit from support workers who know their needs and have gained a relevant qualification. New staff members get to know OLPA’s procedures, but do not receive the recommended induction for working with people in a learning disability service. There is a well-established programme of in-house training. The training programme is being developed, with some new subjects available to staff. Service users are protected by the organisation’s recruitment practices. EVIDENCE: The staff list showed one new member of staff appointed during the last year and another person who was new to the home but already employed with OLPA. Other support workers have worked with the service users for a number of years. A staff member said that the deployment of new staff had reduced the need for agency carers to be used, although it had highlighted the need to ensure that the staff team are consistent in how service users are supported. A staff rota was kept showing the deployment of staff throughout the day. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 19 Five support workers (over 50 of the staff team) have achieved NVQ level 2 or above. One staff member was met with on 25 May 2006 and another on 5 June. A staff member with several years’ experience stressed the importance of being consistent in the way in which service users are supported. This meant encouraging service users to do things themselves, rather than doing things for service users that they could do independently, for example making their own packed lunch before going out for the day. The staff member was concerned that all staff may not adopt this approach. The staff member described their role as key worker, which involved taking the lead on ensuring that a service user’s needs are being met. The staff member had received statutory training through OLPA, but said that there had been no training undertaken during the last year that was specifically related to learning disabilities. In their comment cards, both respondents commented positively in reply to the questions about staffing. Recruitment was discussed with the OLPA personnel officer and service coordinators at the OLPA office. The main employment records were held in the office, with copies of documentation also kept in the home. It was agreed that future arrangements could include inspection of the records at the office and the need to keep records in the home would be removed. However a recruitment checklist would need to be available for inspection in the home. The employment records for a number of OLPA support staff were looked at. Each staff member had an individual file. There was some inconsistency in the files’ contents and in the completion of an employee information form, which is used as a checklist during recruitment. It is recommended that this form is updated, as a number of new recruitment checks have been introduced since the form was produced. The most recently appointed support worker said that she had attended an Induction day at the OLPA office and completed an in-house induction. Some relevant training such as first aid had been undertaken with a previous employer. Following induction, the staff member had attended some training events as part of OLPA’s in-house programme. This had included medication and food hygiene, with abuse prevention planned to take place in the following week. The staff member commented that the events attended so far had tended to repeat previous training, rather than to help develop new skills. Some new subjects have been included in the OLPA in-house training programme for the year ahead. This should be beneficial in developing the staff team’s knowledge of learning disability and care related subjects. Learning Disability Award Framework accredited training is not available and OLPA senior managers have confirmed that it is not the intention to provide this. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 20 Relationships between service users and staff members were observed to be friendly and positive. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before and during the visits to the home. The Commission has not been kept well informed of changes in the running of the home. There is a lack of quality assurance at an organisational level although this is being developed within the home. There are systems in place that help to safeguard the service users’ safety. However, an inconsistent approach to risk assessments may reduce their effectiveness. EVIDENCE: The home’s last registered manager left at the end of 2005. OLPA had not informed the Commission that the registered manager had given notice or had left the home. At the time of this inspection the Commission was dealing with an application to register Bernadette Saunders as the home’s new manager. St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 22 OLPA has achieved the ‘Investors in People’ award. There was no evidence of organisational audit or monitoring of standards in the home. An OLPA policy on quality assurance referred to a number of internal and external devices by which the service is monitored. The policy did not show how these devices contribute to a cycle of planning-action-review, involving timescales and the production of improvement / action plan. There was a ‘Quality Assurance file’ within the home. This contained the minutes of meetings, Regulation 26 reports and a Development Plan for 2006. The plan gave a review of the action that had been taken in 2005,which included staff achieving their NVQ, improvements made to the garden and the kitchen, and service users going on several day trips. The objectives for 2006 included further work on the kitchen, house redecoration and giving service users the opportunity to have a holiday and days away. The Development Plan does not show who has contributed to its contents, or how it will be reviewed as part of a system of quality assurance. Information about health & safety, including the maintenance and servicing of equipment and the checking of the fire precaution systems was received from the home in a pre-inspection questionnaire. The fire alarms were being tested each week. Assessments had been undertaken in respect of environmental and other hazards that may present a risk to service users and / staff. Individual risk assessment records were included in the service users’ personal files. The records did not always show a date for review or what the outcome had been when a review had taken place. An assessment of hot radiators, for example was undertaken in October 2004, with a review date of February 2005, but there was no record of the outcome of this. (See also Standards 6 – 10). Kitchen knives had been assessed as needing to be kept in a secure location where they are not accessible to service users. Staff members said that the knives were counted on a daily basis in order to identify any that may have gone missing. The number of knives and the daily checks were not being recorded. One bedroom door lock was seen. This was of a type that the service user locked from the inside with a key and could not be opened from the outside if the key was left in. This could be a problem if staff needed to get into the room in the event of an emergency. Health & safety matters were being discussed at staff meetings, with minutes kept. A new risk assessment for legionella had been discussed at the meeting in April 2006. . St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 x 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 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 N/A x 2 x x 2 x St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 15 Requirement The registered person must ensure that each service user has a care plan that covers those items specified under Standard 6 of the National Minimum Standards (met in part since last inspection). The registered person must ensure that the Commission is given notice in writing, as soon as it is possible to do so, if the manager leaves, or gives notice to leave, their position. The registered person must ensure that risk assessments are reviewed at least annually and more frequently if any significant changes arise. Timescale for action 30/09/06 2. YA37 39 25/05/06 3. YA42 13(4) 06/06/06 St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 25 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 That a more co-ordinated approach is taken in the recording of the service users’ care, for example by crossreferencing the care plans and the risk assessments. That the information provided for agency carers about the service users’ care needs is reviewed with the aim of ensuring that this is relevant and concise. That staff members have the opportunity to receive training in medication and drug use from an outside, specialist source (recommendation brought forward from previous inspections). That appropriate facilities are provided for hand washing and drying after the washing machine has been used (recommendation brought forward from previous inspections). That the employment checklist is updated to include all aspects of the recruitment process. That LDAF accredited training is provided for new members of staff. (recommendation brought forward from previous inspections). That the policy on quality assurance is amended to include the arrangements made for annual development and for the production of an improvement plan. That the home’s Development Plan shows who has contributed to its contents and how it will be reviewed as part of a system of quality assurance. That a record is kept of the daily check that is made of kitchen knives. That a risk assessment is carried out concerning the type of bedroom locks that are used. (This should also be taken into account in other assessments where appropriate). 4. YA30 5. 6. 7. 8. 9. 10 YA34 YA35 YA39 YA39 YA42 YA42 St Margaret`s Gardens (5) DS0000028372.V289072.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Margaret`s Gardens (5) DS0000028372.V289072.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!