Inspection on 15/06/06 for 53 Cambridge Road

This inspection was carried out on 15th June 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 no outstanding requirements from the previous inspection report, but made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

53 Cambridge Road 29/05/08

53 Cambridge Road 17/05/07

53 Cambridge Road 03/01/06

53 Cambridge Road 06/09/05

53 Cambridge Road 24/03/05

53 Cambridge Road 07/03/05

53 Cambridge Road 18/03/04

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

CARE HOME ADULTS 18-65 53 Cambridge Road Portswood Southampton Hampshire SO14 6UT Lead Inspector Chris Johnson Unannounced Inspection 15th June 2006 10:30 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 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 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 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. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 53 Cambridge Road Address Portswood Southampton Hampshire SO14 6UT 023 8055 1551 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) Choice Support Mr David Minett Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category LD are only to be admitted between the age of 18 years and 60 years 3rd January 2006 Date of last inspection Brief Description of the Service: 53 Cambridge Road is a large detached house, which provides care and accommodation to up to six people who have a learning disability. The home has six single bedrooms and has a large garden, which is accessible to all service users. Choice Support took over the home in 2004 and is now the registered provider. Cambridge Road is situated in Portswood, Southampton close to local amenities and has good transport links. The registered manager of the home is currently seconded to manage another Choice Support home. An acting manager has been appointed to manage the home during this period. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to assess how well the home is doing in the meeting of all key National Minimum Standards and compliance with regulations and previous requirements. The findings of this report are based on a number of different sources of evidence. These included: An unannounced visit to the home, which was carried out over two days. During this visit a tour of the premises was completed that included looking at service user’s bedrooms and all communal areas of the home. Staff and care records were inspected; staff were spoken with and observed in their interactions with residents. All regulatory activity since the last inspection was reviewed and taken into account. Residents completed questionnaires prior to the visit and the acting manager completed a pre inspection questionnaire. Telephone interviews were held with relatives and one care manager. GP’s were also sent questionnaires and one of these had been returned at the time of writing this report. Several requirements were made following this inspection. One immediate requirement was also made. Written and verbal feedback was given to the acting manager at the end of the visit. What the service does well: What has improved since the last inspection? What they could do better: 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 6 A number of requirements have been made as a result of this inspection. Many of these relate to record keeping and can be addressed quite easily however they are vital in ensuring that the intended outcomes for residents are met. An improvement is needed in the standard of written documentation held in the home. At present care plans do not provide enough detail. This means that these plans could not be used in an emergency by people unfamiliar with the residents and there is a likelihood that peoples’ needs will be overlooked. Records that are required to be held at the home to maintain residents safety and wellbeing are lacking, out of date and need to be improved. Improvements need to be made to the medication procedures to ensure residents wellbeing. Infection control is at times compromised by poor practice and the bathing facilities do not meet all residents’ needs. Residents also need to be provided with more information to ensure that they are fully aware of the complaints procedure and the staff need to make themselves familiar with this procedure. 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. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 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 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 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 Quality in this outcome area is Good. This judgement has been made using the available evidence including a visit to this service. People’s needs are fully assessed prior to admission so that the individual and the home can be sure that the placement is appropriate and will meet the person’s individual needs. EVIDENCE: Only one service user has moved into the home since the last inspection. All service users completed a questionnaire and responded that they had received enough information about the home enabling them to make a decision whether the home was right for them. Written information held at the home supported this. Service users are given the opportunity to visit the home have a meal, spend the day and have overnight stays. The home had worked closely with the referring agency and obtained a care management assessment and carried out their own in house assessment all relevant documentation available in the home. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 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): 6,7,8 and 9 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Residents care needs are generally met. However the lack of a care plan for one resident and lack of detail within plans means that there is a likelihood that needs will be overlooked. EVIDENCE: The care plans of 4 service users were looked at during the site visit. No care plan was available for one service user who moved into the home in March. Neither was there a risk assessment in place or risk management plan. However a care management review meeting held recently. The three remaining plans lacked detail and guidance and did not fully address all assessed and identified needs. Staff and the acting manager were in agreement that care plans did need to provide more detail. Whilst the home has relied less on agency cover of late they are still used on occasions. At present the lack of detail recorded means that these plans could not be used in an emergency by people unfamiliar with the service users. This was substantiated by feedback from a GP who stated, “Often residents are supported to attend the surgery by a member of staff who is unfamiliar with the resident’s problem. So communication can be poor”. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 10 The GP Details held in some care plans were incorrect such as next of kin contact details and photos were not available for all residents. Despite this there was evidence that the home was starting to improve on the level of information and commence ‘person centred planning’ with one resident. In discussion with 3 members of staff they were all able to demonstrate a good understanding of each persons’ care needs and describe their care needs and any associated support and methods to be used in good detail. In discussion with a care manager the inspector was told, “I am impressed with how well the home has worked with my client. They have managed her behaviour well and helped her to modify this”. Feedback from relatives was that care needs were managed well and that the staff knew the service users’ needs particularly well. Residents were observed to be able to make their own decisions regarding how they spend their day and lifestyle choices and this was confirmed in feedback from relative/care manager questionnaires and in conversation with residents. Weekly resident menu planning meetings are held in the home whereby all residents have the opportunity to choose the following weeks menu and meetings are held to discuss other topics concerning the home and leisure activities. Residents are supported to take risks as part of their everyday lives. However the lack of any risk assessments for one resident meant that the home was unable to fully demonstrate this. Risk assessments need to be improved all round as currently no one has been risk assessed regarding their ability to self-medicate and all medication is managed by the home. Another resident spoken with said that they wished to access the town centre by on their own without support. The acting manager explained that this would present a risk to the individual however there was not any documentation to support this. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 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): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The opportunities for residents to engage in activities and keep in contact with friends and family are good. They are free to choose how they live their lives and to engage in activities of their own choosing. EVIDENCE: Residents have a range of interests. Most were out at college or day services during the visit or out with staff. Two residents went shopping with staff during the visit one personal shopping and one house shopping. Recommendations had been made following the last 2 inspections that the home should provide a vehicle. In discussion with staff and residents the inspector was informed that residents had now purchased a car. This was to be funded through their disability benefits. All residents spoken with were looking forward to this. Residents said that they had chosen the colour of the car. The acting manager had been instrumental in organising this. Several residents attend college courses to learn new skills and one resident commented that they were looking forward to starting a new course in September. Residents have a good opportunity to take part in activities. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 12 Written and agreed activity programmes were in place in place for each resident and appropriate support is provided. One relative commented that they felt that the level of activity and opportunities to engage in activities was good. Samples of food menus were seen prior to the visit. These demonstrated that residents have a healthy and varied menu. Residents were observed to help themselves to drinks throughout the day and all spoken with said that they prepared their own breakfasts. Feedback from questionnaires was that they were happy with the food. All residents input into the menu planning and one person commented, “Sometimes there is something I don’t like on the menu, if so I have something different”. Care staff mainly prepare the main meal and from discussion with staff and the manager it was agreed that this is something that residents could have more involvement in. The opportunity for residents to keep in contact with their friends and relatives is good. Both relatives spoken with said that they could visit the home whenever they wished and that they were made to feel welcome. They also stated that they were kept informed of any important matters affecting their relative. Residents are free to form relationships and advice is sought from specialist health teams to ensure that residents have appropriate sexual health education. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 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 adequate. This judgement has been made using the available evidence including a visit to this service. Residents are supported with all their healthcare needs. Improvements need to be made to the medication procedures to ensure residents wellbeing. EVIDENCE: Whilst care plans lack detail in some areas they do provide clearer and more detailed descriptions of residents personal care needs. The majority of personal care provided currently consists of prompts and verbal reminders. Where assistance is required this is described satisfactorily within the care plan. All residents that returned a questionnaire or who were spoken with said that they received enough help with their personal and healthcare needs. The health care records were examined for four people. All were well maintained. There was plenty of evidence from records that residents have access to a full range of health care support including specialist teams and that their healthcare is monitored. All relatives spoken with reiterated this. The medication administration records were checked for several residents during the site visit. Whilst the home has in-house policies and procedures for the handling, storage and administration of medication, some errors were found in the administration records whereby there were gaps in the records and so it could not be established easily whether the person had received their medication or not. Procedures for the recording of medication are not always 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 14 followed. Several residents have been prescribed ‘as required’ (PRN) medicines and there was not any guidance to inform staff regarding the use of these. Neither was it referred to in their individual care plan. On several persons files there was some guidance regarding their support needs with medication, however this information was found to be out of date and one member of staff spoken with was unaware of that this information existed. At present no one is self–medicating and risk assessments have not been completed to determine residents ability to manage their own medication. This was despite one person’s admission assessment stating that they were able to self-medicate. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 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 adequate. This judgement has been made using the available evidence including a visit to this service. Residents feel confident that their concerns will be listened to. However they do need to be provided with more information to ensure that they are fully aware of the complaints procedure. EVIDENCE: No concerns regarding the home have been reported to the Commission for Social Care Inspection since the last inspection. A Complaints log is maintained in the home, and from examination, the home had not received any complaints. This was supported by pre-inspection material and feedback from relatives. Residents and relatives all reported that they had not had cause to complain. The inspector discussed with one resident what they would do if they were unhappy about anything and they said that they would tell member of staff if. Another resident showed the inspector their information file. It was noted that they had not been issued with a complaints procedure and there was a lack of evidence that this had been explained to them. Although most residents responded in the questionnaires sent to them prior to the site visit that they knew how to complain. One did not, and the staff member assisting with the form recorded that this had now been explained to them. Evidently this needs to be made clearer and discussed with them and the procedure needs to be supplied to them in an appropriate format. Staff spoken with were also unclear of the complaints procedure. At the last inspection a requirement had been made that all staff must be made aware of adult protection procedures. Training records showed that nearly all staff had now completed training in this area and arrangements had been made for remaining staff to attend the course. In discussion with staff they were all able to demonstrate an adequate level of 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 16 awareness and understanding of the principles. Referral forms are held in at the home to refer any concerns. The manager was however unable to locate a copy of the local authoritys Adult Protection Procedure. A requirement was made that a copy of this is obtained for future reference to ensure that the manager and staff are fully aware of reporting procedures. Staff support residents with their finances and records were checked of all transactions. These were found to be correct and thorough receipting and recording is maintained. Currently the home looks after several residents’ building society books amongst other things. A record is not currently kept of these and this will need to be done. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 17 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): 24,25,27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Residents live in a homely, clean and safe environment. Infection control is at times however compromised by poor practice and the bathing facilities do not meet all residents’ needs. EVIDENCE: A tour of the premises took place on the first day of the visit. The home was clean throughout, well presented and homely. Residents have a choice of two lounges, a large kitchen/diner, a garden and their own rooms. Both lounges have televisions. Staff said that this proved popular as it enabled residents to have a greater choice regarding which television programmes they could watch. A gazebo had been erected in the garden so that residents could enjoy the garden in the shade and this was popular. Residents were observed to have access to all areas, as was their choice. During a telephone interview prior to the visit a care manager commented, “It feels like it is their home, residents answer the door. It is warm, welcoming and friendly”. Relatives spoken with prior to the visit remarked that the home was always clean whenever they visited. Maintenance records demonstrated that maintenance issues are highlighted and dealt with appropriately and that the home is maintained safely. The 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 18 inspector saw several residents’ bedrooms and these were personalised with residents’ own belongings and reflected their individuality. All residents spoken with said that they were happy with their rooms and each person had a key to his or her own room. All residents have been supplied with a cash tin in their rooms to safeguard their valuables. However these are not suitable as they are portable and do not offer sufficient safeguards. Residents require more secure storage this is especially important to any resident who is to look after their own medication. One resident did have a safe in their room however this had a combination type lock and was unsuitable for their need. It was noted that hand towels were not available in two of the toilets neither was there any hand soap in one. This was pointed out to staff on the first day of the visit but they had still not been replaced on the second day. The current bathing facilities are not suitable to meet all residents needs, do not fully promote independence and do not offer choice. Two residents have mobility problems and the manager reported that one had been referred to the physiotherapist for an assessment. The bathing facilities in the home comprise of two bathrooms. Both have shower attachments. One is designed to be used overhead, although this had neither a curtain nor a screen. The second bath is very low and the shower attachment is only suitable to use if sat down and would not enable anyone regardless of mobility to wash their entire body. Neither of these shower attachments is suitable for residents with mobility problems and it was reported that the low bath proved difficult for at least one resident to access. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 19 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): 31,32,34,35 and 36 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home maintains adequate staffing levels and provides appropriate support, supervision and training to ensure that staff provide a good standard of care. EVIDENCE: From examination of the homes rota there are sufficient staffing levels of staff on duty at any given time of the day to ensure that the needs of residents are met. Since the last inspection additional members of staff have been employed. Whilst bank workers are used quite frequently, these are consistently the same people and there is now less reliance on agency staff. This benefits residents as it often takes them a considerable time to build trusting relationships with staff and offers them greater consistency. Everyone spoken with prior to the visit spoke very highly of the staff team. Residents reiterated this and appeared to be relaxed and at ease with all members of the team. One resident commented, ”The staff are nice. They help me make my bed, help me with my laundry and with my money”. The inspector observed staff to be respectful, polite and supportive. Choice Support provides staff with a broad training programme most of which is delivered at the company’s local area office. Examination of staff training records demonstrated that they attend all necessary core health and safety training as well more service specific training. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 20 All residents are allocated a key worker and this seems to work well. All residents spoken with said that they were happy with this arrangement. Staff receive regular supervision and in discussion they said that they felt that the level of support provided to them was good. Appraisals were at the time of this inspection being implemented as required at the last inspection. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 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): 37,38,39,41 and 42 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The acting manager is accessible and sensitive to the needs of service users. The standard of record keeping needs to be improved to ensure that service users’ best interests are safeguarded. At present the home has no quality assurance system in place and therefore cannot fully demonstrate that the home is run in the best interests of residents. EVIDENCE: The registered manager has been seconded to manage another Choice Support home and has not been at Cambridge Road for several months. This arrangement is anticipated to carry on until at least October 2006. In the absence of the manager an acting manager has been recruited. At the time of this inspection The Commission for Social Care Inspection had not received an application to register the acting manager as had been agreed. This must be carried out to ensure that there is an accountable person managing the home on a day-to-day basis and to comply with regulations. Staff, residents, 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 22 relatives and social care professionals reported that they found the new acting manager supportive and approachable. It was evident that the acting manager is keen to improve the service and to provide a good standard of care to the residents. The acting manager is at the home for a sufficient time each week to oversee the day-to-day running of the home and reports directly to senior manager within the organisation. The value base and ethos of the management and staff team appear to be in the best interests of residents. and all previous requirements have been met or are in the process of being met. This inspection has however highlighted a number of areas that require improvement many of which are related to the standard of record keeping. Besides those discussed throughout this report it was found that several records concerning residents details were incorrect or out of date including next of kin and GP details. Photographs were not available for residents these are particularly important to aid with identification should a resident go missing. Although some records were found during the course of the visit they were not readily attainable and do need to be more organised and accessible to all staff. Choice Support has an agreement with The Commission for Social Care Inspection that some staff records can be held centrally rather than in the home. The inspector viewed the information held at the home of newly appointed staff and was satisfied that all appropriate checks and had taken place prior to commencement of employment. However within this agreement homes are required to keep a record on a proforma capturing all records required by regulations. This was not being done and some records were clearly not in place. The home is regularly visited and monitored by a senior manager within the organisation and reports are submitted to the Commission for Social Care Inspection as required. However the home does need to establish a quality assurance system for the purpose of monitoring the services and care delivered in the home. At present there is no system in place to ascertain the views of residents, their representatives or stakeholders and this means that the home is unable to assess whether it is meeting its aims and objectives and to put an improvement plan in place. The home appeared to be safe and is well maintained. From inspection of the fire logbook regular and thorough testing of the homes fire detection equipment had taken place. It was noted that regular inspection of the home’s fire fighting equipment had not taken place and it was agreed that the manager would seek advice as to the frequency that these checks must take place. Regular health and safety checks are undertaken with a senior member of staff overseeing this process. Certificates were available to demonstrate that equipment used within the home is regularly serviced and checked. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 2 28 3 29 2 30 2 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 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 3 2 X 2 3 2 X 1 3 X 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (1) 13 (4) (c) Requirement A care plan must be put in place for the resident identified during the inspection. This must detail the persons care needs and provide staff with sufficient guidance as to the level and method of support that this person requires. It must also highlight any risks to the person and detail how these can be managed. All care plans must be reviewed. They must be more detailed and provide specific support instructions and fully address all assessed and identified needs including the identification of any risks and how these are to be managed. Procedures must be followed for the receipt, recording, and administration of medication. Written guidance must be produced in respect of any resident prescribed PRN medication. Risk assessments must be completed on all residents to determine their ability to self medicate. DS0000059160.V289388.R01.S.doc Timescale for action 16/06/06 2. YA6 15 (2) (b) (c) 16/08/06 3 4 YA20 YA20 13 (2) 13 (2) 16/07/06 16/07/06 5 YA20 13 (2) 16/08/06 53 Cambridge Road Version 5.1 Page 25 6 YA22 22 7 YA23 12 (1) (a) 8 YA23 17 (2) Schedule 4 16 (2) (c) 9 YA26 10 11 YA30 YA27 16 23 (2) (j) 12 YA37 8 14 YA39 24 (1)(2) (3) 15 YA41 19 Schedule 2 17 (1) (a) Schedule 3 The Complaints procedure must be produced in a suitable format explained, and issued to all residents. You must obtain a copy of the local authority’s adult protection procedure and make this available at to all staff. A record of all valuables deposited by a service user or received on their behalf must be maintained. Service users must be supplied with secure lockable storage in their rooms. This needs to be appropriate to their needs. Adequate supplies of towels and hand soap must be made available in toilets. An action plan must be submitted to The Commission for Social Care Inspection detailing the plans to provide suitable bathing/showering facilities that meets service users needs. An application must be submitted to the Commission for Social Care Inspection for registration. The registered manager must establish a quality assurance system at appropriate intervals for monitoring the services and care delivered in the home. This must be done in consultation with the service users and their relatives/ representatives to gain views and opinions. Results of quality assurance monitoring must be made available to the CSCI. All records listed in the schedules must be maintained and held in the home. 16/09/06 16/07/06 16/07/06 16/08/06 16/07/06 16/07/06 01/08/06 16/09/06 16/07/06 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 26 16 YA42 13 (4) (c) You must seek the advice of Hampshire Fire and Rescue regarding the frequency of checks to be carried out on fire fighting equipment and take action appropriately. 16/07/06 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 Refer to Standard YA17 YA20 YA20 YA30 Good Practice Recommendations That following a risk assessment, residents are given more opportunity to be involved with meal preparation. That a copy of the guidelines produced by the Royal Pharmaceutical Society of Great Britain is obtained. That the current monthly audit of the medication records is carried out more frequently. That paper towels are made available in all toilets. 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 53 Cambridge Road DS0000059160.V289388.R01.S.doc Version 5.1 Page 28 - 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. 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