Inspection on 22/06/07 for 60 Wood Lane

This inspection was carried out on 22nd June 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

60 Wood Lane 19/08/08

60 Wood Lane 03/05/06

60 Wood Lane 24/01/06

60 Wood Lane 01/07/05

60 Wood Lane 04/01/05

60 Wood Lane 13/07/04

60 Wood Lane 14/01/04

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

CARE HOME ADULTS 18-65 60 Wood Lane Sonning Common Oxfordshire RG4 9SL Lead Inspector Marie Carvell Unannounced Inspection 22nd June 2007 1:00 DS0000013219.V340667.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 DS0000013219.V340667.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. DS0000013219.V340667.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 60 Wood Lane Address Sonning Common Oxfordshire RG4 9SL 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) 01189 722080 jenny.pearce@new-support.org.uk www.new-support.org.uk New Support Options Limited Mrs Jennifer Pearce Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (3) of places DS0000013219.V340667.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 3 3rd May 2006 Date of last inspection Brief Description of the Service: 60 Wood Lane is a three-bedroom house situated in a quiet residential area of Sonning Common, close to shops and other amenities. It provides residential care for up to three adults with a learning disability, either under or over 65 years of age. Two of those being supported at this time were older people. All those being supported are admitted on a permanent basis. The physical dependency of those being supported is increasing as they become older and consideration is being given as to how these needs can be met in the future, possibly through building an additional two ground floor rooms. Social and Community Services purchase all the places in the home. The home is owned and managed by New Support Options Ltd, a charitable organisation that provides residential, supported living and outreach services for adults with a learning disability. The current charges are £641.18 per person per week. Extras include podiatry and hairdressing and those being supported buy their own toiletries, papers and magazines and pay transport costs out of their own weekly allowance. DS0000013219.V340667.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘key Inspection’. The inspector arrived at the service at 1pm and was in the service until 5pm. It was a thorough look at how well the service was doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection. Two service users, a relative of one service user, an advocate of one service user, a care manager (social Worker) and two general practitioners responded to surveys that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standards of the service. Time was spent with two service users, very briefly with the manager and the two staff on duty during the inspection, a tour of the premises was carried out and a sample of records required to be kept in the home were examined, including the case tracking of two service user’s files. At the last inspection carried out in May 2006, one requirement and two good practice recommendations were made. The requirement was that the menu plans are recorded in sufficient detail so that anyone examining these can determine the adequacy of the food provided. This has been complied with. The good practice recommendations were to ensure that 50 of staff are trained to NVQ Level II and review the recommended policies and procedures at least every three years. These have not been actioned. What the service does well: There has been one service user admitted to the home since the last inspection. Records seen demonstrated that a full needs assessment was obtained on the prospective service user prior to admission to the home for a trial period. Following a period of settling in supported by home staff, social care professionals and relatives a meeting took place to decide whether the home was able to meet the service user’s needs. Comments made on surveys completed by service users included ‘ I came to visit and had tea with my new housemates. I then came and stayed for a weekend. X my care manager told me about the home. My family also visited the home’ All service users have an individual contract and statement of terms and conditions of their residency in the home. DS0000013219.V340667.R01.S.doc Version 5.2 Page 6 Daily routines are relaxed and appear to be flexible to meet the service users preferences. Comments made on the relative/advocate surveys regarding whether the home provided the support and care expected included ‘ Excellent, particularly the extra- curricular activities’. From discussion with the two staff on duty, they were able to demonstrate a clear knowledge of the service users’ needs and preferred lifestyle. Service users were observed to be treated with dignity and respect. The manager confirmed that all staff complete mandatory training and evidence was seen of a staff training and development programme and applications submitted for future training courses. Both support workers confirmed that they receive regular, planned supervision and this was evidenced for one support worker. Staff meetings are held regularly and staff handovers take place at the start of a shift. Records relating to health and safety were seen to be well maintained and up to date. What has improved since the last inspection? What they could do better: During the inspection the attention of the member of staff on duty was drawn to the fact that lunch provided was egg and mayonnaise sandwiches and the evening meal was an omelette. Neither member of staff on duty were aware of the home’s whistle blowing policy or if there was a policy in place. The home continues to have vacancies for two part time support workers and a full time senior support worker. The inspector was advised that staff are not currently being recruited to these vacancies. At the time of this inspection one support was on duty until 3pm, having come on duty the previous day at 2.30pm. At 3pm a second support worker came on duty until 2.30 pm the next day. The duty roster was misleading as it stated that the manager was working 9am until 5pm and a support worker was working 5pm until 10pm. The manager later explained that the duty roster covered two care homes and the hours recorded for the manager and the support worker were for a second care home. The manager has since advised DS0000013219.V340667.R01.S.doc Version 5.2 Page 7 the Commission that she has made some amendments to the duty rosters to clearly identify the name of the member of staff, the hours rostered to work, in which home and whether the roster was actually worked. Staffing levels are minimal, five full time and one part time support workers are in post to cover two care homes, totalling 205 hours per week. In addition a bank support worker covers shifts in both homes for approximately 10-15 per week. One of the support workers on duty said that she had been in post for eight weeks and had not yet received training in first aid, food hygiene, health and safety or moving and handling. Training courses had been booked for later on in the year. Support from the manager was available by telephone only as the manager was the only member of staff on duty at the second home. The personnel file of the most recently recruited member of staff was brought to the home by the manager, as these are kept at another care home. Not all pre – employment checks were on file. No photograph was on file, no evidence of police checks being undertaken, no evidence of the person being physically and mentally fit, no documentary evidence of any relevant qualifications and no evidence that a formal interview had taken place. Following the inspection the manager confirmed that all police checks had been completed prior to employment in the home. The personnel file did contain evidence of an induction programme and a medication assessment. One support worker has completed NVQ level III and one support worker is working towards NVQ level II, the remaining staff are on a waiting list. The manager is also the registered manager for a second care home and divides her time between the two homes. In addition the manager supports a service user who lives in the community. It is not evident that the manager has sufficient time to carry out her some of her administrative and management responsibilities at Wood Lane, as the manager is covering long term support worker vacancies and providing sleep in duties at two care homes. At the last inspection a good practice recommendation was made that policies and procedures are reviewed at least three yearly. The manager confirmed that this had not yet happened as all policies and procedures were to be reviewed when New Support Options becomes Dimensions. Staff on duty were not familiar with the organisations policies and procedures. Only two proprietor representative reports were available in the home. The manager explained that these reports are kept at the second home, as the proprietor representative completes only one joint report to cover both homes, referred to as “The Sonning Homes”. The manager has since advised the Commission that a separate report for Wood Lane will be written following an unannounced visit to the service. DS0000013219.V340667.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000013219.V340667.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000013219.V340667.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 4. Quality in this outcome area is good. All service users are assessed prior to moving into the home and are given the opportunity to stay for short periods to be clear whether the home meets their individual needs. Each service user has a detailed contract of residency, which is available in appropriate formats. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been one service user admitted to the home since the last inspection. Records seen demonstrated that a full needs assessment was obtained on the prospective service user prior to admission to the home for a trial period. Following a period of settling in supported by home staff, social care professionals and relatives a meeting took place to decide whether the home was able to meet the service user’s needs. Comments made on surveys completed by service users included ‘ I came to visit and had tea with my new housemates. I then came and stayed for a weekend. X my care manager told me about the home. My family also visited the home’ All service users have an individual contract and statement of terms and conditions of their residency in the home. DS0000013219.V340667.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): Standards 6,7 and 9. Quality in this outcome area is good. Service users have detailed care plans and are as involved as much as possible, with decision making. Appropriate risk assessments are in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are completed with input from the service user, key worker and the service user’s representatives, as appropriate. Care plans are detailed and include the likes, dislikes and preferences of the service user, daily routines and activity programmes. The service user’s key worker regularly updates care plans. Regular review meetings are held to ensure that any changing needs are being addressed. Risk assessments are in place to support care plans and are used to inform staff of the ability of service users to make informed choices and decisions. DS0000013219.V340667.R01.S.doc Version 5.2 Page 12 Surveys completed by a relative and an advocate confirmed that they are kept informed of important matters. A survey completed by a relative commented, ‘ my wife and I recently attended X annual ‘Planning’ event and was very impressed with the content and conduct’ From discussion with the two staff on duty, they were able to demonstrate a clear knowledge of the service users’ needs and preferred lifestyle. Service users were observed to be treated with dignity and respect. DS0000013219.V340667.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): Standards 12,13,15,16 and 17. Standard 17 was subject to requirement at the last inspection. Quality in this outcome area is good. Service users are assisted to make informed choices regarding all aspects of their daily life. This is sometimes dependent on staff resources. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users have a weekly programme of activities. Daily activities are recorded in service user records. The home has its own vehicle, which is shared with another home, however, due to only two members of staff being able to drive, use is restricted. Records demonstrated that a wide range of outings and activities take place. One service user works six days per week at a local farm and has done so for many years, one service user attends day services for two days per week and the third service user attends day services for one morning per week. During the inspection two service users were at DS0000013219.V340667.R01.S.doc Version 5.2 Page 14 home, watching television and knitting. Any activities undertaken during the day, outside the home, are dependent on the consensus of all service users wishing to participate, as there is usually only one member of staff on duty. Comments made in service user surveys included ‘ I like to watch my DVDs and videos, sometimes to go out in the car if a driver is working’, ‘ My work on the farm is very important to me, so apart from Sundays I like to go every day’. Since the last inspection two service users have been on holiday to Dawlish. Service user’s rights and responsibilities are respected and this is evidenced in service user records. The right to be alone is respected by staff, who do not enter bedrooms without permission. Service user (House meetings) are held monthly and are well attended. Visitors to the home are made welcome. Service users birthdays and other events in the home always include friends and families. Service users are encourages to maintain regular contact with family members. Daily routines are relaxed and appear to be flexible to meet the service users preferences. Comments made on the relative/advocate surveys regarding whether the home provided the support and care expected included ‘ Excellent, particularly the extra- curricular activities’, ‘ As far as I am aware. Sometimes new staff come and are not “au fait” with making contact with me. However, they all are, I feel sure very kind and supportive to X’. From the evidence seen and in discussion with staff on duty, the inspector considers that the home would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. At the last inspection a requirement was made that menu plans are recorded in sufficient detail so that anyone examining these can determine the adequacy of the food provided. This has been complied with. Records of meals provided are included in service users’ daily records. The attention of the member of staff on duty was drawn to the fact that lunch provided was egg and mayonnaise sandwiches and the evening meal was an omelette. It was not clear whether this had been the choice of the service users. Food stocks were plentiful, with fresh fruit, salad and vegetables. DS0000013219.V340667.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): Standards 18,19 and 20. Quality in this outcome area is good. Service user’s personal and healthcare needs are well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users’ physical and personal support needs are detailed in care plans and are recorded in daily records. Service user’s records evidenced that healthcare checks are undertaken as necessary. Two surveys received from general practitioners stated that both were satisfied with the overall care provided to service users and would take up any concerns directly with the home. Since the last inspection, handrails have been fitted in the bathroom to assist service users to maintain their independence when bathing. Medication is administered by staff who have received appropriate medication training. Records of medication administered were up to date with no obvious gaps in recordings. DS0000013219.V340667.R01.S.doc Version 5.2 Page 16 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): Standards 22 and 23. Quality in this outcome area is adequate. The home has a complaints procedure in an appropriate format for service users. Staff need to be aware of the home’s whistle blowing policy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure has recently been updated and is available in pictorial format for service users. Comments made on service user surveys included ‘ I know to speak to one of the staff or my care manager X and they would help me’ (if I had a concern or complaint), ‘ sometimes I forget’. Comments made on surveys completed by relatives/advocate stated that they were aware of how to make a complaint. The home has not received any complaints since the last inspection and the Commission has not received any information regarding complaints about this service since the last inspection. Staff on duty confirmed that they had received training in safeguarding adults from abuse. However, neither member of staff on duty were aware of the home’s whistle blowing policy or if there was a policy in place. DS0000013219.V340667.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25,27,28 and 30. Quality in this outcome area is good. Service users live in a homely and comfortable environment that currently meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection some internal and external decoration has been completed and a new drive, path and patio have been laid. The communal areas of the home consist of a small sitting room and dining room. The dining room is also used as the home’s office and contains a single bed, which is used by the member of staff undertaking ‘sleeping in’ duty at night. This is not an ideal use of the dining room, however, it is acknowledged that there is no other suitable area available in the home. The home is comfortable, domestic in size and homely. DS0000013219.V340667.R01.S.doc Version 5.2 Page 18 One bedroom was seen at the invitation of the service user. The bedroom was comfortable, appropriately furnished and reflected the interests of the service user. The service user was able to choose the colour scheme of the room and choose matching soft furnishings. There is one bathroom on the first floor of the home, but no separate toilet facilities. Consideration should be given to installing a ground floor toilet. The laundry facilities are sited in the kitchen. The home was found to be clean, fresh smelling and well maintained. DS0000013219.V340667.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34,35 and 36. Standard 32 was subject to a good practice recommendation at the last inspection. Quality in this outcome area is adequate. Staffing levels are stretched to meet the needs of the service users; staff continue to work long shifts due to staff shortages. Recruitment procedures need to be more robust. The ratio of NVQ qualified staff remains poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff on duty were clear about their role and responsibilities. Since the last inspection one new member of staff has been recruited. The home continues to have vacancies for two part time support workers and a full time senior support worker. The inspector was advised that staff are not currently being recruited to these vacancies. At the time of this inspection one support was on duty until 3pm, having come on duty the previous day at 2.30pm. At 3pm a second support worker came on duty until 2.30 pm the next day. The duty roster was misleading as it stated that the manager was working 9am until 5pm and a support worker was working 5pm until 10pm. DS0000013219.V340667.R01.S.doc Version 5.2 Page 20 The manager later explained that the duty roster covered two care homes and the hours recorded for the manager and the support worker were for a second care home. The manager has since advised the Commission that she has made some amendments to the duty rosters to clearly identify the name of the member of staff, the hours rostered to work, in which home and whether the roster was actually worked. Staff on duty were unaware of whether there was a lone working policy in place. Staffing levels are minimal, five full time and one part time support workers are in post to cover two care homes, totalling 205 hours per week. In addition a bank support worker covers shifts in both homes for approximately 10-15 per week. One support worker has left since the last inspection. One of the support workers on duty said that she had been in post for eight weeks and had not yet received training in first aid, food hygiene, health and safety or moving and handling. Training courses had been booked for later on in the year. Support from the manager was available by telephone only as the manager was the only member of staff on duty at the second home. The personnel file of the most recently recruited member of staff was brought to the home by the manager, as these are kept at another care home. Not all pre – employment checks were on file. No photograph was on file, no evidence of police checks being undertaken, no evidence of the person being physically and mentally fit, no documentary evidence of any relevant qualifications and no evidence that a formal interview had taken place. Following the inspection the manager confirmed that all police checks had been completed prior to employment in the home. The personnel file did contain evidence of an induction programme and a medication assessment. The manager confirmed that all staff complete mandatory training and evidence was seen of a staff training and development programme and applications submitted for future training courses. One support worker has completed NVQ level III and one support worker is working towards NVQ level II, the remaining staff are on a waiting list. This was subject to a good practice recommendation at the last inspection. Both support workers confirmed that they receive regular, planned supervision and this was evidenced for one support worker. Staff meetings are held regularly and staff handovers take place at the start of a shift. DS0000013219.V340667.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39,42 and 43. Standard 42 was subject to a good practice recommendation at the last inspection. Quality in this outcome area is adequate. The manager needs to be provided with sufficient time and resources to manage the home effectively. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is managed by a well qualified and experienced manager. The manager is also the registered manager for a second care home and divides her time between the two homes. In addition the manager supports a service user who lives in the community. It is not evident that the manager has sufficient time to carry out her some of her administrative and management responsibilities at Wood Lane, as the manager is covering long term support worker vacancies and providing sleep in duties at two care homes. DS0000013219.V340667.R01.S.doc Version 5.2 Page 22 At the last inspection a good practice recommendation was made that policies and procedures are reviewed at least three yearly. The manager confirmed that this had not yet happened as all policies and procedures were to be reviewed when New Support Options becomes Dimensions. Not all policies and procedures were available during this inspection as they are kept at another care home and the inspector declined the request to visit in order to access these records. Staff on duty were not familiar with the organisations policies and procedures. Only two proprietor representative reports were available in the home. The manager explained that these reports are kept at the second home, as the proprietor representative completes only one joint report to cover both homes, referred to as “The Sonning Homes”. The manager has since advised the Commission that a separate report for Wood Lane will be written following an unannounced visit to the service. Records relating to health and safety were seen to be well maintained and up to date. DS0000013219.V340667.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 2 DS0000013219.V340667.R01.S.doc Version 5.2 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 YA33 Regulation 18 Requirement Timescale for action 22/08/07 2 YA34 19 and Sch 2 24 3 YA37 A plan of action must be put into place to ensure that sufficient staff are employed to meet the assessed needs of the service users. Staff records must evidence that 22/08/07 all pre-employment checks have been carried out and that a formal interview has taken place. The registered manager must 22/08/07 have sufficient time to carry out her management responsibilities. DS0000013219.V340667.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 4 5 Refer to Standard YA17 YA23 YA32 YA33 That all support staff are provided with training/updating in the home’s whistle blowing policy. Ensure 50 of staff are trained to NVQ Level 2. That consideration is given to the current practice of staff working long shifts, and consider using additional bank/agency staff to cover staff vacancies. Review the recommended policies and procedures at least every three years. That all staff are familiar with the home’s policies and procedures. Including the home’s lone working policy. Good Practice Recommendations That consideration is given to meal planning to avoid repetition of foods, served at consecutive meal times. YA42 DS0000013219.V340667.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 DS0000013219.V340667.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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