Inspection on 23/05/07 for 52 Winchester Road

This inspection was carried out on 23rd May 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

52 Winchester Road 22/08/06

52 Winchester Road 16/01/06

52 Winchester Road 30/08/05

52 Winchester Road 08/11/04

52 Winchester Road 22/06/04

52 Winchester Road 10/07/03

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 08/07/2008.

CARE HOME ADULTS 18-65 52 Winchester Road Four Marks Alton Hampshire GU34 5HR Lead Inspector Marilyn Lewis Unannounced Inspection 23rd May 2007 09:30 52 Winchester Road DS0000011642.V336176.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 Winchester Road DS0000011642.V336176.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 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 52 Winchester Road Address Four Marks Alton Hampshire GU34 5HR 01420 564028 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) ILIACE Limited vacant post Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2006 Brief Description of the Service: 52 Winchester Road is registered to provide care and accommodation to four people between the ages of 18 and 65 years with learning disabilities. The home is owned by Iliace ltd and is a four bedded detached property situated in the village of Four Marks, a ten minute drive from the town of Alton which has a range of leisure, educational and employment facilities. All service users have their own bedroom, communal space and a large garden, which accommodates an indoor heated swimming pool. The acting manager reported, during the inspection on the 23/05/07, that the fees at the home are approximately £1475.90 per week, depending on the needs of the service users. 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on the 23rd May 2005. The inspector met with the four service users and two support workers and toured the home. Records seen included service users care plans, medication, complaints, fire safety and drills and staff recruitment and training. Since the last inspection two managers have left the home and an experienced manager employed by the organisation was providing cover as acting manager until a new manager started work at the home in June 2007. The acting manager had previously been the manager of 52 Winchester Road and knew most of the service users resident there. The area manager for the organisation was also providing support and advice to service users and staff at the home. The acting manager and area manager were both involved in assisting the inspector during the visit. Prior to the visit survey forms were sent to service users and their relatives to obtain their views on the quality of care provided at the home. These views and information provided by the home since the last inspection were used in the completion of this report. What the service does well: Service users said that they liked living at the home and during the visit they looked relaxed and at ease with staff. Good interaction was seen between staff and the service users. Service users are encouraged to maintain their independence and make their own decisions about their lives. The home provides good information about life at the home for people wishing to move there. No one is admitted without a care needs assessment to ensure the home can meet their care needs. The service users said that they felt any complaints would be taken to seriously and acted upon. During the visit a service user discussed a concern with the acting manager, whom he said listened to him and said that she would investigate the issue. Although the service users written activity programmes were not up to date, service users and staff knew what activities were due to take place. Service 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 6 users said that they were able to choose what they wanted to do and staffing levels were flexible to allow for the activities to take place. Service users said that they discussed the menus for the week before they went shopping for groceries. They said that the food provided was always good and they were never hungry. The home looked clean and homely. Service users said that they had chosen the furniture for their room, which contained many personal items such as televisions and music centres. A service user who escorted the inspector to see his room said that he liked the room and it was ‘his space’. Two support workers on duty during the visit said that they liked working at the home and one commented that they ‘worked as a team’. What has improved since the last inspection? Care plans and risk assessments seen for the four service users on this visit, showed evidence of improvement and recent review. The area manager and acting manager were aware that further improvement was needed to ensure service users needs were met and risks minimised. Staff were working with service users to provide a more person centred approach to the care plans, which would include more comments on the wishes and ambitions of the service users. A service user said that he knew what was written in his care plans and he agreed with them. The acting manager was aware that risk assessments were required for all daily living and social activities and was in the process of writing risk assessments for activities such as visits to restaurants and local activity centres. Medication records sampled had not been completed accurately at the last visit. Records seen on this visit were up to date and had been completed appropriately. Staff said that they had recently received training in the safe handling of medicines, which minimised the risk to service users. At the time of the last visit some recruitment records seen for staff did not contain two written references and evidence that Criminal Records Bureau (CRB) checks had been completed to ensure staff were suitable to work with the service users. Records seen during this visit contained all the information required and CRB checks had been undertaken for new staff members. 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 52 Winchester Road DS0000011642.V336176.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 Winchester Road DS0000011642.V336176.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): 1, 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel they are provided with good information about the home and are able to visit before making a decision about taking a place there. No one is admitted to the home without a care needs assessment to ensure the home can meet their care needs. EVIDENCE: One service user has moved into the home since the last inspection. The service user had moved from another home run by the organisation and care plans were already in place. A welcome pack was provided for the service user before he moved homes that gave him information on life at the home and included photographs of the environment, resident service users and staff. The photographs of staff identified the staff members who would be visiting him at his existing home to undertake a care needs assessment. The care assessments were detailed and contained information that included personal care, communication, social and health needs. Reports from the care manager were included in the completed assessment. 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 10 The service user visited the home once during the transition period. Further visits that had been planned were cancelled as the service user wished to move into the home quickly. Information provided in a questionnaire completed by another service user indicated that the service user felt that he had been given good information about the home and had visited before deciding to move in. 52 Winchester Road DS0000011642.V336176.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning and risk assessments have improved since the last inspection but require further improvement to ensure that all the service users care needs are met and risks are minimised. EVIDENCE: The care plans were seen for all of the service users. The care plans had recently been reviewed and were in the process of being changed to a person centred plan method of care planning. A support worker, who was a key worker for a service user, said that he was reviewing each part of the plan with the service user to ensure the service user’s wishes were incorporated in the documents. A service user said that he knew what was written in his care plans and agreed with them. The plans provided clear guidance for staff on the care needs and wishes of the service users including, in the case of a service user who could have challenging behaviour at times, the triggers that might cause the challenging behaviour and the actions to take when it occurred. 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 12 The plans noted that staff were to encourage and support service users to make their own decisions. It was evident during the visit that this was happening. Service users made decisions about going out, to college and for activities around the home such as getting themselves a drink or snack. The care plans had improved since the last inspection but further improvement was needed to ensure all health care information was recorded. One care plan stated that the service user needed to visit a chiropodist but there was no indication that an appointment had been organised. A staff member confirmed that the appointment was being made but had not been documented. Also one service user had information on foot exercises in his care plan and although staff confirmed the exercises were undertaken, there was no record of this in the care plans. The care plans contained risk assessments including those for bathing, medication, use of electrical appliances, assisting in the kitchen and fire safety. The acting manager said that risk assessments were being completed for social activities such as going out to restaurants and places of interest. Letters from GPs confirming that there was no reason why service users should not use a trampoline or the swimming pool were contained in the care plans and risk assessments were being completed for these activities. 52 Winchester Road DS0000011642.V336176.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, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users choose which social and leisure activities they wish to participate in, are supported to maintain relationships with family and friends and enjoy the meals provided. EVIDENCE: The acting manager said that some of the service users had been assessed as able to go out into the community independently and daily records seen indicated that one service user had visited the local shops alone recently. Service users also go out using the organisation’s transport, which picks them up from the home. One service user attends courses at a local college and the other three service users attend sessions arranged by the organisation. The service user who attends college told the inspector that he was looking forward to going there in the afternoon to do woodwork. 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 14 Records seen indicated that service users visited local shops, restaurants, pubs and local parks. A service user chatted to the inspector about going to various shops in the locality and said that he was going to buy items for his bedroom later in the week. At the time of the last inspection staffing levels were not always sufficient to allow service users to undertake leisure activities. On this visit service users said that they were able to attend their courses and undertake leisure activities as they wished. The area manager said that staffing levels were flexible to allow time and support for activities. Although service users and staff were aware of the programme of activities for each service user, the activities programmes in place in care plans, were out of date and did not provide the correct information on the service users leisure and educational activities. The acting manager said that these would be updated to ensure no sessions were missed. The programmes also needed more details as to what activities were to take place when time was spent at home as the documents just stated ‘at home’. During the visit service users chose what they wished to do with one service user going off to college, one spending time in the garden, one in his room watching television and one chatting to a staff member in the lounge. The acting manage said that service users chose not to attend religious services and at the time of the visit there were no service users resident who were from a different ethnic minority. Records seen indicate that some of the service users have very frequent contact with relatives through visits and telephone calls. Care plans for one service user said that he enjoyed meeting with a female friend weekly at her home. Service users said that staff treated them with respect and good interaction was observed between staff and service users during the visit. Service users also chatted together and looked to be ease with one another. Staff were seen to knock on doors and ask permission before entering rooms and they spoke to service users in a friendly manner. Service users said that they met to discuss the menus for the week before going shopping for groceries. They said that they enjoyed the food provided and they were able to help themselves to snacks such as fruit as they wished. The care plans for one service user gave guidelines for staff on encouraging healthy eating. At the time of the visit there was very little food in the home but the acting manager said that they were due to shop later that day. Service users said that they were never hungry and knew that the shopping was due to take place. 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel they are receiving personal support in the way they prefer and are protected by staff following the home’s procedures for the safe handling of medicines. EVIDENCE: Care plans documented the service users preference for the way in which they received personal care, such as what time they usually wished to take a bath or shower. The plans noted that staff needed to prompt some service users to complete their personal care such as cleaning their teeth. One service user said ‘I can go to bed or have a bath when I want to’. Records were kept of visits to GPs and other health professionals and care plans seen contained letters giving advice including one from the consultant psychiatrist regarding a service users medication dosage. Records of visits to dentists and opticians were also made and notes made of how the service user coped with the consultation. 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 16 As previously noted in standard 6, appointments made for the chiropodist were not always recorded and confirmation that an exercise programme arranged by a physiotherapist was followed was not available. Medication was kept in a locked cupboard in the staff office. At the time of the visit only creams and Paracetamol tablets were being prescribed. Medication records seen had been completed appropriately. Staff provided one service user with his prescribed cream and stayed with him while he applied it to ensure it was applied as required and then signed the medication records to confirm the cream had been administered. This method of recording the administration of cream had been changed following the last inspection when the practices used were not in line with the organisation’s policies and procedures for the administration of medication. The home had systems in place for recording medication coming into the home and on disposal of unwanted medicines. Staff said that they had recently attended training in the safe handling of medicines but no records were available to confirm this. 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users know that any complaints would be taken seriously and acted upon. Systems followed by staff for handling money did not safeguard the financial interests of some of the service users. EVIDENCE: Service users said that they would talk to a staff member if they had any concerns or complaints and this was confirmed when during the visit a service user asked to speak with the acting manager about something he was not happy with. The acting manager discussed his concerns with him in a sensitive manner. The service user said after the discussion that he felt the acting manager had listened to him and was going to take action to resolve the issue. The home has policies and procedures in place for the protection of vulnerable adults. A staff member said that they would report any suspected abuse to the person in charge of the home and was aware that the concerns should be reported to the Adult Protection team for investigation. Staff said that they had received training in the prevention of abuse but records were not available to confirm this. Staff have followed the appropriate procedures when recent incidents of suspected abuse between service users occurred and they notified Adult 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 18 Services and the commission. Staff worked with staff from the Adult Protection team in investigating the incidents. The home holds personal money for service users. The money is held in individual containers in a locked cupboard. Receipts are kept for all transactions. The records were not completed in a clear manner and staff had not signed when entering amounts taken out of the containers. The area manager and the inspector checked the containers and found that only one contained the amount on the records. The amount held for two service users was £12 and £17 less than recorded and the other one contained £12.52 more. The area manager said that he would arrange for an audit of the accounts to be undertaken by someone external to the home to take place as soon as possible. The area manager also said that a new system for handling the money would be put in place to minimise the risk of errors. Records seen for two staff members who had started work at the home since the last inspection indicated that CRB and POVA checks had been completed to minimise the risk to the safety of the service users. 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean, safe and homely environment for all who live, work and visit there. EVIDENCE: Service users said that the inspector was able to tour the home and look at their bedrooms. Each service user has a single room and access to the communal lounge, dining area and kitchen. The service users said that they liked their rooms and had personalised them with items such as posters, television and computer systems. The rooms looked clean, bright and cheerful. The home has sufficient bathroom and toilet facilities. An office is located on the first floor. All service users are mobile and able to use the stairs. There is no lift. 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 20 The kitchen, which is domestic in style, looked clean and in good order. The washing machine is situated in the kitchen. Staff said that laundry is not taken through the kitchen or the washing machine operated when food is being prepared or meals are taken. During the tour of the home it was noted that hazardous substances such as cleaning fluids were stored securely. Radiators in the home were not covered. The area manager said that risk assessments were in place and the risk to service users had been assessed as low. The inspector was shown the completed risk assessments. No service users at the home were susceptible to epilepsy and had been assessed as being able to move away from the radiators if required. The home has gardens to the rear and side of the property and there is also a covered swimming pool. The pool building is locked when the swimming tutor is not present for swimming sessions. A key pad system is in operation on the front gate to minimise the risk of service users who have been assessed as not able to leave the home alone, do not leave unattended. Service users who are able to leave the home alone are not aware of the key pad number, but will ask staff to let them out when they wish to leave the home. On arrival at the home a service user, opening the front door, asked the inspector to sign the visitors book. 52 Winchester Road DS0000011642.V336176.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): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Robust procedures are used in the recruitment of new staff members to protect the safety of the service users. Staff are not receiving the supervision required to provide them with feedback on their performance and records are not available to confirm that staff have received the training required to fully support the service users. EVIDENCE: Rotas seen indicated which staff member was responsible for the running of the home when the acting manager was not on duty. Staff spoken with knew who to contact for advice and support during these times. The area manager said that there was always a home manager on call and that he was also on call for assistance should it be necessary. The home has a key worker system whereby a support worker is allocated as the person who will have most contact with the service user and will attend reviews and health consultations. A key worker on duty was aware of the responsibilities of the role. He said he was in the process of talking through the care plans with service users to ensure their wishes are recorded. 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 22 The area manager said that although the key worker system was in place, meetings were to be held with staff to develop the role further such as the key worker attending multi disciplinary reviews. Service users and staff said that enough staff were on duty for each shift. Two support workers were on duty during the morning and afternoon and one ‘awake’ night support worker. The acting manager usually worked Monday to Friday. The acting manager said that service users were fairly independent with some able to go out alone and others going out with other staff from the organisation while using transport or attending activities at other centres. Staff on duty said that there had been a high turnover of staff over the last year and this was commented on by a relative who returned a completed survey form to the commission. However the staff said that liked working at the home and felt they worked as a team. Training records were not up to date. One staff member said that they had completed NVQ training but records did not confirm this. At the time of the visit no staff members were attending NVQ training. Staff members also said that they had attended training in adult protection, medication, infection control, food hygiene and challenging behaviour but again there were no records to confirm this. The acting manager was undertaking an audit of training requirements and had already arranged for training for all staff in health and safety, first aid and fire safety. A complete audit of training received and required needs to be completed and action taken to ensure staff receive the training required to do their jobs. At the time of the last inspection records seen for staff recruitment did not contain the information required and indicated that staff had commenced work at the home before Protection of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) checks had been completed. Records seen at this visit for two staff members contained all the information required including two written references and POVA and CRB checks. One staff member said that they had received supervision from the previous manager but this had not been recorded. Other staff members had not received one to one supervision as required to ensure they receive feedback on their personal performance and to discuss any issues or concerns and training requirements. 52 Winchester Road DS0000011642.V336176.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, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users feel their views are taken into account in the running of the home. The home lacks stable leadership and poor record keeping could result in the health, safety and welfare of the service users and staff being put at risk. EVIDENCE: Since the last inspection there have been two managers who have left the home and staff said that they felt a ‘bit at a loss’ for leadership and support. A staff member said that they hoped the new manager due to start work at the home in June would stay in position and offer the support needed. During the period of change in manager, a manager who works for the organisation and has previously run the home is taking the role of acting 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 24 manager to provide management support for staff and service users. The area manager is also taking an active role in supporting the home. The area manager said that the new manager due to start work soon, was an experienced manager with management qualifications. She had visited the home and met with service users, who said that they liked her. The area manager said that a staff meeting was being held shortly to keep staff up to date with changes and provide an opportunity for them to discuss any issues or concerns. No service user meetings were being held but the area manager said that one to one meetings were taking place as the service users wished. A staff member said that he met frequently with a service user for whom he was the key worker. Two service users said that they could talk with staff about ‘anything’ and they said that they discussed changes to life at the home such as new staff members and the new manager. The service users had met with the new service user before he moved into the home and had agreed on his coming to live with them. One of the service users had told the acting manager that he was unsure about staying at the home and a meeting had been arranged with his care manager to discuss this. The area manager said that a survey on the quality of care provided at the home would be undertaken when the new manager was in post to provide a base to work from and to prioritise areas for improvement. Survey questionnaires were provided for service users and their relatives prior to the visit to obtain their views on the quality of care provided at the home. Completed questionnaires were received by the commission, from the relatives of two service users and from one of the service users. Overall the feedback was positive. Accident reports indicated that all accidents were recorded and reported where necessary. Records for the recording of the fridge and freezer indicated that there had been issues at times with the temperatures not being at the correct level to keep food safe. A comment in the record book said that it was the thermometer that was faulty and not the appliances but no checks on the thermometer or appliances had been recorded to confirm this was the case. At the time of the last inspection visit there were concerns that the temperatures of the appliances were not being kept at the correct level and staff thought it was then because the doors of the appliances were not being closed properly. The acting manager said that new thermometers would be obtained and if these indicated that the appliances were not working properly they would be checked by a service engineer. A fire risk assessment had been completed for the home in February 2007 and records seen indicated that checks of fire safety equipment were being carried 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 25 out. However records for fire drills were not up to date and did not confirm that staff had attended fire drills. 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 26 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 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 2 x 2 x 2 2 x 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 27 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 YA23 Regulation 13 (6) Requirement An audit must be undertaken of the records of money held for service users. Any discrepancies are to be corrected to ensure service users financial interests are safeguarded. An audit of training required by staff must be undertaken and actions taken to ensure staff receive the training needed to do their jobs. Staff must receive supervision at least six times a year to ensure they receive feedback on their performance and have the opportunity to discuss any concerns and training requirements. Records of staff attendance at fire drills must be kept up to date and staff who have not attended drills must attend fire drills at regular intervals to ensure the safety of the service users should a fire incident occur. Timescale for action 30/06/07 2. YA35 18 (1) (c) 30/06/07 3. YA36 18 (2) 31/07/07 4. YA42 23 (4) (e) 30/06/07 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 52 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Winchester Road DS0000011642.V336176.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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