Inspection on 30/11/06 for 52 Wellington Road

This inspection was carried out on 30th November 2006.

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

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

Other inspections for this house

52 Wellington Road 29/08/07

52 Wellington Road 19/12/05

52 Wellington Road 14/06/05

52 Wellington Road 17/03/05

52 Wellington Road 17/03/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 52 Wellington Road Taunton Somerset TA1 5AP Lead Inspector Pippa Greed Unannounced Inspection 30th November 2006 09:05 52 Wellington Road DS0000039964.V317554.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 52 Wellington Road DS0000039964.V317554.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. 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 52 Wellington Road Address Taunton Somerset TA1 5AP 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) 01823 334132 01823 327560 Milbury Care/ Voyage South Care Home 12 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 12 persons in categories LD and PD Key Inspection - 19th December 2005 Random Inspection – 21st April 2006 Date of last inspection Brief Description of the Service: 52 Wellington Road is registered with the Commission for Social Care Inspection to provide care for up to 12 people in the categories of LD (learning disability) and PD (physical disability). The home is a large older style house situated within walking distance of Taunton town centre and many other local facilities. All service users rooms are for single occupancy and there are a variety of communal areas. Milbury Care / Voyage South Limited owns the home. The current scale of charges is £900 to £1,500. 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key inspection was conducted over one day (8hrs) by CSCI Regulation Inspector Pippa Greed. On the morning of the inspection, six support workers and the manager were on duty and during the afternoon there were four support workers. There were two waking night staff rostered for that evening. The home manager Mrs. Samantha Murphy was available to assist the inspector during the unannounced visit. The registered manager Mrs Jackie Seward has since left the organisation. Samantha Murphy is currently applying to register with the Commission. On the day of the inspection eight service users were at home. One service user left around mid morning to attend Fitness & Toning Table session. Another service user went for a walk with staff. A review meeting was held for one service user. During the afternoon, a cookery session took place and most service users participated fully and appeared to enjoy the activity. The atmosphere was purposeful and informal. Staff were seen to work professionally and demonstrated good rapport with the service users. The inspector viewed all communal areas and three service users rooms with their expressed permission. The inspector met with and engaged with six service users. The inspector sat with and had lunch with the service users and staff and also observed daily routines within the home. The inspector met with two staff members. The inspector also met with family members and social worker to listen to their views regarding the care provided at 52 Wellington Road. The overall feedback was positive. A selection of records was examined. These included three service users care plan and three staff recruitment files. CSCI sent out feedback cards to four relatives, one health care professional and one General Practitioner. Two comment cards were received from parents. The parents wrote respectively; ‘(service user) always received the finest possible care at No. 52. Staff are always extremely professional, courteous and helpful in every way’, ‘(service user) has never been happier and has improved markedly after his move’. One nurse wrote ‘I have only visited twice. However, on those occasions I was impressed by the attitudes and care given by staff to a client whom has extremely complex needs’. The GP confirmed that the home demonstrated a clear understanding of the care needs of service users. The inspector would like to thank the service users, staff, and manager for their time and hospitality shown to the inspector during her visit. The inspector would also like to thank the family members and social worker for their input. 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 6 The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: What has improved since the last inspection? What they could do better: One requirement and nine recommendations were made at this inspection. Continued efforts must be made to increase the number of qualified staff to ensure to ensure that the staff team has the skills and experience to provide a good level of care. This relates to mandatory training updates. 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users and their families are provided with relevant information regarding the home. Social and health assessments are being completed to ensure that the home will be able to meet service users’ needs. EVIDENCE: The home has an updated Statement of Purpose that provides details of the services and facilities provided at 52 Wellington Road. The service users care plan included a Service User’s Guide, which outlined what the service provides. The Service User’s Guide is provided in Picture bank format, which uses pictorial symbols. The symbols are easy to understand and the guide explains what the prospective service user can expect from 52 Wellington Road. This enables the service user and their family to make an informed choice. Updated social and health assessments are currently being completed by the home manager in order to ensure that the home continues to meet service users’ needs. One care plan sampled evidenced that the home obtained prospective service user’s details and detailed overview prior to moving into the home. A written 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 10 profile and detailed assessment is obtained from the social worker, which would allow for Voyage’s Operations Manager to assess the suitability for placement. There is no set timescale as each case is judged on the service user’s needs. Each service user has an individual written contract/statement of the terms and conditions with the home. This is developed between the Placing Authority and Voyage. The contract is kept at Voyage Head office in Taunton. There are three vacancies at present. The manager is aware of the need to ensure that an assessment of care need is completed prior to any prospective service user viewing the home. 52 Wellington Road DS0000039964.V317554.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are encouraged to exercise choice and participate in all aspects of life within the home. Service users are supported in taking risks. Records relating to service users are stored securely and appropriately maintained. EVIDENCE: Care plans are maintained for each service user. Three care plans were examined in detail. Care plans included a photograph of the service user, and provided information regarding service users needs. The care plans includes health care provision, daily and monthly records, service user’s guide, inventory of belongings, medication records and finance records. The service user’s guide includes a complaint procedure and Protection of Vulnerable Adult guidance. This is written in a simple and clear format with some pictures. The manager is currently completing updated individual risk assessments for each 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 12 service user. It is recommended that individual risk assessment for choking risk be written to confirm safe practice in place. The manager plans to further develop and update care plans at the home. The Behaviour Management Guidelines would benefit from recorded review dates at an appropriate frequency in relation to the service user’s needs. Service users are encouraged to exercise choice, and independence is promoted. The service users who live at the home have complex needs and require support and assistance in all aspects of daily living. The Inspector observed how support were offered at mealtimes and staff spoken with were evidently clear on service users health and dietary needs. The Inspector spent some time sitting in the lounge observing interaction by staff with service users. There was positive interaction with service users. Service users were seen enjoying and participating in tasks within the home. It is recommended that more consideration be given to how service users can be ‘formally’ involved in such topics as menu planning and decisions affecting the home. The home operates a Key worker system to ensure that the home continues to meet the needs of each service user. Staff will support service users in managing their finances where required. Financial records were examined for two service users. All entries were supported with one staff signature. The manager has recently implemented a finance form, which demonstrates daily checks are made and two staff signatures support this. Currently, no service users have the support of an independent advocacy service. All records relating to service users are stored securely and kept confidential. 52 Wellington Road DS0000039964.V317554.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home offers service users opportunities to engage with peers, access appropriate leisure activities, and exercise choice. Service users rights and responsibilities are respected. Service users are offered a choice of menu, and were seen to enjoy the meals provided. EVIDENCE: Service users are supported in developing and maintaining daily living skills. Staff from the home will assist service users in continuing to access social and leisure resources. On the day of the inspection, eight service users were at home. One service user attended a Fitness & Table toning session during the morning. One service 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 14 user went for a walk with a staff member and one service user had a review meeting held with family members and social worker. The review meeting was considered by those who attended as positive and constructive. Activities provided by the home and in the wider community includes the following: holistic therapy, massage, bread making, creative ability, music and art, hydrotherapy, horse & cart, ten pin bowling, horse-riding, fitness & toning tables and swimming. The home has regular contact with service users family members. Care plans provide details of service users personal and family relationships. There are many photographs of service users and their families in individual bedrooms. The home has a menu that reflects the likes and dislikes of the service users. The menu offered for the week provided a balanced and nutritious diet. The hallway board depicts the meal for the day with simple symbols and photographs. On the day of the inspection, breakfast time was relaxed and unhurried. The Inspector sat with and dined with the service users whilst observing the lunchtime routine. Service users were seen to be enjoying their meals and staff offered care and support in a kind manner. 52 Wellington Road DS0000039964.V317554.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are provided with appropriate assistance to meet their personal care needs. The home supports service users in accessing healthcare services. The home has aids and adaptations to assist the service users in their personal support. The home promotes service user’s privacy and dignity. Medication Administration Records were seen to be well maintained. EVIDENCE: Service users are provided with support to undertake personal care tasks as required. Staff support service users in accessing healthcare services and ensure that specialist advice is sought as necessary. Care plans sampled evidenced referrals made to specialists such as speech and language therapist, psychiatrist and Social Services Learning Disability team. The home has been proactive in meeting service users changing needs be it behavioural or medical. The Inspector also spoke with family members regarding the health care support and they confirmed that the home has been supportive with this. 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 16 The home has aids and adaptations to assist the service users in their personal support. Where needed service users have the use of technical aids and equipment. The home has adapted cutlery, drinking cups, plates and bowls. At present service user use wheelchairs when out but no lifting required. All bedrooms have en-suite facilities so this promotes service users’ dignity when supported with personal care. However, one service user’s bedroom would benefit from a screen installed on the en-suite doorway. The Inspector sampled the Medication Administration Record and storage of medication. This was checked and seen to be well maintained. The Medication Administration Record file had medical footnote and photograph ID of each service user. Staff are provided with medication training. A list of staff signatures demonstrated which staff is authorised to administer medication and help identify whose signature is recorded on file. There are audits in place to check stock and expiry dates for each service user’s Prescription Required as Needed (PRN) medication. There are clear audit trail for medication booked into the home. The home maintains records of service users medication leaving the home for overnight visits. This is good practice. No gaps were seen on the Medication Administration Record and appropriate levels of stocks were stored. The medication storage area was clean and tidy. It is recommended as good practice that liquid medications are labelled to demonstrate dates when opened and when to dispose by. The home has a policy relating to ageing and death. The care plans does not contain details relating to standard 21. 52 Wellington Road DS0000039964.V317554.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place for the Protection of Vulnerable Adults from abuse. Many staff have not received an update in POVA training. The home has a complaints procedure and policy relating to the Protection of Vulnerable Adults. However, the home’s ‘Whistle Blowing’ policy does not include the Commission’s and Social Services contact detail. EVIDENCE: The home has appropriate policies relating to the Protection of Vulnerable Adults, Whistle Blowing, Complaints policy, and Grievance policy. The Inspector met with two staff members and asked about their understanding of Safeguarding Adult procedures. Staff were clear on who to report to should they suspect abusive practice. POVA training should be offered to all staff to ensure that they are familiar with protection issues and reporting procedures. The last recorded complaint was made in August 2006. Whilst the home has a complaint log in place, the complaints policy should make clear to complainants that they are able to contact the Commission for Social Care Inspection at any stage of a complaint. 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 18 The Inspector sampled the company’s Whistle Blowing policy. Section 4.4 could be further improved to demonstrate to the Whistleblower that they can raise concerns outside the organisations if they wished. The Public Interest Disclosure Act 1998 provides clear ‘good practice’ guidance. Three staff recruitment files were sampled and these contained information required by Schedule 2, Care Homes Regulations 2001. Criminal Records Bureau (CRB) checks are in place for all staff. POVA 1st checks have been carried out on newly recruited staff. 52 Wellington Road DS0000039964.V317554.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has been decorated and furnished to a good standard. The home has sufficient communal areas and bathrooms to meet service users’ needs. The home was found to have a good standard of cleanliness. EVIDENCE: 52 Wellington Road is a large Victorian terraced property situated in the town. Service user accommodation is provided over three floors. The home comprises of a lounge, dining room, day room, three toilets, laundry room and kitchen. There are sufficient communal spaces for service users to access. There is a large enclosed patio to the rear of the property that provides picnic table and benches. There is also an attractive lawn to the front of the property, which is screened by well-established trees and secure fencing. 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 20 Service user rooms are single occupancy. All rooms have an en-suite bathroom. Some have Jacuzzi baths. Service users rooms have been decorated to a good standard and are personalised with their own belongings, television and DVD player, sensory lighting and decorative posters. One service user’s bathroom has been upgraded with a new bath, toilet and sink. The ground floor bedroom has been redecorated and converted into a day room to provide quiet space for service users to relax in or access massage. The lounge has also been redecorated recently with new flooring, curtains and décor. Three service users bedroom have also been redecorated. The laundry area was secure, clean and well organised. Appropriate hand washing facilities had been provided for staff throughout the home. The home had been maintained to a high standard of cleanliness. In the kitchen the Inspector saw records of daily fridge and freezer temperatures. These were found to be within safe range. The food stored in the fridge was date labelled to promote good food hygiene practice. Food probe records were seen and maintained within appropriate range. New kitchen worktops have been installed recently. The kitchen is equipped sufficiently and kept clean. 52 Wellington Road DS0000039964.V317554.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff are experienced and provide a good standard of care. Staffing levels are appropriate to meet service users’ needs. Mandatory training updates for the staff is required. Staff receive appropriate support and supervision. EVIDENCE: Duty rotas are maintained appropriately. On the day of the inspection, the home was staffed with seven staff (including the manager) during the morning, five staff during the afternoon and two waking staff at night. It was reported that six new staff have joined the service since the last key inspection. Staff spoken with confirmed that they had received appropriate support and regular supervision. Staff file evidenced that supervision are being provided. 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 22 Staff meeting are being provided regularly. It is recommended that staff are provided with formal one to one supervision at least six times a year. Observation of care provided throughout the inspection process showed that the staff team are caring and demonstrated good understanding and rapport with the service users. Staff spoken with confirmed that they fully understood their role. Three staff recruitment files were examined which included evidence of enhanced CRB disclosure being obtained. The files contained documentation required by Schedule 2 of Care Homes Regulation 2001. The induction file provided a comprehensive guidance on induction training which included Policy & Procedure, Learning Disability awareness, Manual Handling, Infection Control, Risk Assessments, Control of Substances Hazardous to Health (COSHH), Accident & Incident reporting, Food Hygiene, Fire Safety, Health & Safety, Abuse awareness, Stress management and support worker’s role. The staff training matrix was viewed and there is evidence that the staff team are undergoing a programme of training updates throughout the year. Training topics included Induction, Food Hygiene, Learning Disability Awards Framework (LDAF), Non Violent Crisis Intervention (NVCI), First Aid, Health & Safety, IT, Rectal Diazepam, and Manual Handling. Future training is planned to provide; Intensive Interaction, Total Communication, further mandatory training, National Vocational Qualification (NVQ) level two and management development training. It is required that staff are provided with mandatory training updates. The Pre-Inspection Questionnaire provided stated that four staff from nineteen have completed NVQ 2 or above. However, it is recommended that all staff are provided with Protection of Vulnerable Adult training and further increase the level of NVQ trained staff. 52 Wellington Road DS0000039964.V317554.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is managed well. There is a relaxed and open atmosphere within the home. Appropriate actions have been taken to promote the health and safety of staff and service users. EVIDENCE: The home manager is Mrs Samantha Murphy. She is presently applying to the Commission to register as manager for 52 Wellington Road. She has many years experience of providing care to service users with learning disabilities. She has worked as a registered manager at another Voyage home for four years. She has a deputy and three senior support workers to support her. 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 24 The Inspector has received very positive feedback from relatives and social worker in relation to the management of the home. One family member said ‘The staff act professional. They have approached things in a very professional way and Sam is very efficient’. Staff have stated that Sam is open, listens to staffs’ views and shows leadership skills. Staff at the home seek service users’ views on an individual basis, taking account of behaviours, verbal and non-verbal communication. There was a total communication approach and this was evident throughout the inspection process. The home has effective quality assurance and quality monitoring systems. There is an annual development plan and each home within the Company has an annual review that is conducted by the Operational Manager as well as monthly visits to the home (Regulation 26 visits). The home has appropriate policies and procedures in place to safeguard vulnerable service users. All records relating to service users are stored securely in accordance with the Data Protection Act 1998. The home has a current Employers Liability insurance. Fire equipment is serviced and tested as required. All staff members had been provided with updated fire safety training in October 2006. The electrical hardwiring certificate, Portable Appliances Testing (PAT) and Gas Landlord Safety certificates have been appropriately maintained. Accidents and Incident records were seen to be in place. The Inspector discussed with the manager about further details recorded and monthly analysis as good practice. The manager plans to address this with the team. Records are kept of daily fridge and freezer temperatures and food probes. These were maintained appropriately. Hot water temperature check was made on 7th October 2006. It is recommended that water temperatures from hot water outlets are recorded weekly to ensure it is not above 43 degrees Celsius. 52 Wellington Road DS0000039964.V317554.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 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 4 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 3 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA35 Regulation 18 (1) (c) (i) Requirement It is required that all staff are provided with mandatory training updates. Timescale for action 08/03/07 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. 2. 3. 4. 5. Refer to Standard YA9 YA8 YA9 YA20 Good Practice Recommendations It is recommended that Behaviour Management Guidelines are dated and reviewed at an appropriate frequency in relation to the service user’s needs. It is recommended that service users are offered formal opportunities in decision making within the home such as small service users meeting or menu planning. It is recommended that individual risk assessment for choking risk be written to confirm safe practice in place. It is recommended as good practice that liquid medications are labelled to demonstrate dates when opened and when to dispose by. It is recommended that the complaints policy make clear to complainants that they are able to contact the Commission for Social Care Inspection at any stage of a complaint. Also, to include contact details of the Commission. DS0000039964.V317554.R01.S.doc Version 5.2 Page 27 YA22 52 Wellington Road 6. YA23 7. 8. 9. YA35 YA36 YA42 It is recommended that the Whistle Blowing policy (point 4.4) is further improved to demonstrate to the Whistleblower that they can that they can raise concerns outside the organisations if they wished. It is also recommended that Protection of Vulnerable Adult (POVA) training be provided for all staff. Also, to further increase level of NVQ trained staff in the home. It is recommended that staff are provided with formal one to one supervision at least six times a year. This was a recommendation made at the last two inspections. It is recommended that water temperatures from hot water outlets are recorded weekly to ensure it is not above 43 degrees Celsius. 52 Wellington Road DS0000039964.V317554.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 52 Wellington Road DS0000039964.V317554.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. 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!