Inspection on 13/06/06 for 61 Adkin Way

This inspection was carried out on 13th June 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

61 Adkin Way 04/01/07

61 Adkin Way 21/11/05

61 Adkin Way 04/07/05

61 Adkin Way 05/01/05

61 Adkin Way 12/08/04

61 Adkin Way 09/02/04

61 Adkin Way 02/02/04

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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 61 Adkin Way Wantage Oxfordshire OX12 9HN Lead Inspector Nancy Gates Unannounced Inspection 13th June 2006 10:30 61 Adkin Way DS0000013060.V303966.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 61 Adkin Way DS0000013060.V303966.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. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 61 Adkin Way Address Wantage Oxfordshire OX12 9HN 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) 01235 762279 adkin.way@unitedresponse.org.uk www.unitedresponse.org.uk United Response Elizabeth Webb Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2005 Brief Description of the Service: 61 Adkin Way is registered to provide 24-hour residential care and support for up to four people with a learning disability. It is a detached house with a garden and is similar in style to the neighbouring properties. It is domestic rather than institutional in character. At the time of this inspection the home was providing long-term accommodation and support for four people who had lived there since it was first registered. The home is managed by United Response, an organisation with experience of working with people with a learning disability, although the premises are owned by a housing association. Service users are registered with a local GP practice and have access to specialist services as required. The average fee for this service is £2043.30 per week. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. From the 1st April 2006 the Commission for Social Care Inspection (CSCI) has developed the way it undertakes the inspection of care services. The inspection of the service was an unannounced ‘key inspection’. The inspector arrived at the service at 10.30 am and was in the home for 8 hours. The time spent at the home allowed for a thorough look at how well the service is doing. The inspection took into account detailed information provided by the service manager inclusive of information that CSCI has received about the service since the last inspection. The inspector asked for the views of the people who use the service. The inspector also asked the views of others who support the needs of the people who use the service via a questionnaire that the CSCI sent out. Three members of staff were on duty, later joined by the registered manager. The members of staff and the residents were generally welcoming. The inspector looked around the home including the bedrooms of the residents at their invitation. A number of records were viewed including a resident’s care plans, staff recruitment records, staffing rotas and maintenance records. The inspector looked at how well the service was meeting the standards set by the government. The report includes judgements about the standard of the service. What the service does well: A committed and respectful staff team supports resident’s personal needs. Changes in health status are recognised and acted upon. Relationships with families are promoted; the views of family members are listened to. A healthy, balanced and varied diet is offered to all residents. Access to additional support from health care professionals including members of the Community team for People with Learning Disabilities (CTLD) is consistent and provides additional guidance to resident’s health and support needs. Medication is stored securely and administration is accurate, ensuring residents safety. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 6 A clear complaints process is available to residents and their representatives and the protection of residents is assured by the availability adult protection guidance. A reasonably clean and comfortable home is provided. Residents have personal and shared space that meets their current needs. From the evidence seen, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. The quality of the service is monitored regularly with actions required. Health and safety checks are conducted appropriately. What has improved since the last inspection? What they could do better: Support plans contain numerous documents that support the needs of residents. The quality of the information is varied and does not demonstrate that residents are being included in decisions being made about their lives. A number of documents must be reviewed and updated. The home needs to continue to explore opportunities for residents to find appropriate education and training or to take part in a variety of fulfilling activities. The staff could demonstrate more clearly that resident’s independence, choice and freedom is being promoted. The high usage of agency staff does not ensure consistent support that meets resident’s needs. The inconsistency in staff knowledge and competence does not fully ensure the protection of residents. Staff files need to be reviewed to include all information required for the protection residents. The management and conduct of the home has been inconsistent and has lacked boundaries for the safe support of residents. A deputy manager has been recently employed at the home due to the registered manager having a number of management commitments within 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 7 United Response. This should ensure that the management support is consistent. 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. 61 Adkin Way DS0000013060.V303966.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 61 Adkin Way DS0000013060.V303966.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality of the outcomes in this area is adequate. This judgement has been made using available evidence including a visit to the service. No admissions have been made to the home, although the assessments completed for current residents provide adequate information for admission. EVIDENCE: No admissions have been made to the home since the previous inspection. The assessments completed for current residents provide adequate information for admission. The current fee for this service is £2043.30 per week. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 10 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 & 9 The quality of the outcomes in this area is poor. This judgement has been made using available evidence including a visit to the service. Support plans contain numerous documents that support the needs of residents. The quality of the information is varied; a number of documents must be reviewed and updated. Daily records do not uphold the principles of confidentiality. Staff are knowledgeable and respond to residents needs. EVIDENCE: The care plans of four residents were viewed. The previous inspection of the 21st November 2005 highlighted that the home planned to introduce ‘Active Support Plans’ for each person, this remains outstanding and incomplete. Care/support plans/files are sometimes inconsistent in recording the needs and wishes of individuals. The quality of the information is, on occasion, inadequate or non-existent. The registered manager must ensure that staff adequately record changes. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 11 In contrast, communication profiles, daily routines and records of appointments with doctors, dentists or opticians are of a good standard and provide important information. Behavioural support guidance is clear and recognise the perception of the wider community/neighbourhood. Guidelines in relation to behavioural support needs are available completed with support of a psychologist from the Community Learning Disability Team. Whilst guidance is available increased incidents of challenging behaviour for one individual resulting from increased anxiety levels have not been reported to the community team members, “…we are disappointed that the monitoring information has not been forwarded to us.” Further comments regarding the quality of the behavioural support provided at the home in the ‘Personal and Healthcare Support’ section of this report. A number of risk assessment relating to resident’s challenging support needs are outdated and must be reviewed to ensure the health and welfare of all household members. Family members have assisted one individual to produce a person centred plan highlighting the wishes of the individual and how they want to be supported. The inclusion and lead of family members is positive and inclusive but should not negate the responsibility of the home to ensure that care and support plans are up to date and relevant to the needs of individuals. The registered manager stated that a number of staff are to complete training regarding person centred planning. United Response have stated their commitment to ensuring person centred plans/active support plans will be clear and consistent. The inspector welcomes that training is being provided but timescales need to be established as to when the active support plans/person centred plans will be completed. Daily records are currently completed for all residents in a hand over book. The entries record daily activities for each person, but do not uphold principles of confidentiality. This must be changed. Staff were respectful, committed and supported residents appropriately throughout the inspection. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 The quality of the outcomes in this area is adequate. This judgement has been made using available evidence including a visit to the service. The lifestyle choices of residents are not recorded appropriately. Efforts have been made to use a person centred planning tool to record resident’s wishes. Relationships with families are promoted appropriately. The views of family members are listened to. A healthy, balanced and varied diet is offered to all residents. EVIDENCE: Previous inspection have highlighted a need for the manager and staff to explore the wishes of residents in relation to finding activities that they enjoy. The registered manager stated that active support plans will help to develop the opportunities for residents although the process is has just started. The inspector could not find adequate evidence that this has been addressed; no clear records were apparent regarding progress in this area. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 13 All staff promote links with residents’ family members. Regular house meetings involving parents have been established allowing people the opportunity to air views regarding the quality of support provided to family members. All residents participate in the planning of menus. Choices are shown as pictures, residents also have favourites, which are included within the menu. Menus run on a six-week basis. Drinks are available at all times to household members. Residents are expected to participate in shopping, meal preparation and cooking and do so with the support of staff. A new kitchen has been installed and provides a clean place to prepare and cook meals. The dining room allows people to eat together with staff support. The decoration and cleanliness of the dining room is of a reasonable standard although the wall lights need to be repaired or removed and replaced. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 14 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 & 20 The quality of the outcomes in this area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ physical healthcare needs are appropriately supported. Access to additional support from health care professionals is consistent, although specialist advice is often not implemented. Medication is stored securely and administration is accurate, ensuring residents safety. EVIDENCE: Resident’s support plans detail the level of support needed to provide personal care. Local doctors, dentists and opticians support health care needs; staff support residents appropriately. The monitoring of residents behavioural support needs is completed with the support of the Community Learning Disability Team (CLDT). Reviews are undertaken on a regular basis, although the advice of clinicians is not always used. Comments regarding the quality of the service were received by the CSCI from professional contacts “The home has frequent problems managing 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 15 challenging behaviour. Advice regularly sought – not usually adequately implemented…quality of front line staff questionable…lack of decent line management which is not good enough for a supposedly specialist service.” The registered manager stated that the current recruitment issues have resulted in inconsistency in approach and will be addressed in the future through supervision and ongoing support. Whilst the inspector welcomes the line management support implemented, the registered manager must recognise that the support of professionals is a valuable resource for ensuring consistency in behavioural support for residents. Consistency of approach when supported by clinical advice and guidance should be respected and implemented. A local pharmacist supplies the home with medication stored within a blister pack dispensing system. Medication administration records are supplied by the pharmacist to support accurate administration and recording. Recording is accurate; no omissions were noted, as the process adopted at the home requires two staff to oversee dispensing. Medication administration and recording is of a good standard. No ‘controlled drugs’ are currently used. Staff confirmed that medication training and tests have to be undertaken to ensure competency in dispensing and recording. 61 Adkin Way DS0000013060.V303966.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The quality of the outcomes in this area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are supported make complaints through a clear procedure. Residents are protected by the policy documentation and by staff knowledge regarding the protection of vulnerable adults. EVIDENCE: The United Response complaints procedure has been made available to residents in picture format. Guidance and policy information regarding the protection of vulnerable adults is available at the home. Training is also provided to staff. Money held for residents is recorded accurately. A recent incident following a lack of consistency resulted in a serious allegation being made regarding one household member. The home manager is due to report the outcomes and actions following the incident in due course to the CSCI. 61 Adkin Way DS0000013060.V303966.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The quality of the outcomes in this area is adequate. This judgement has been made using available evidence including a visit to the service. A reasonably clean and comfortable environment is provided; service users bedrooms reflect individuality. A number of maintenance and cleanliness issues must be addressed. EVIDENCE: A tour of the home was conducted with a member of staff and with the permission of residents. One resident has a bedroom on the ground floor with an adjacent shower room. The bedroom contained belongings that reflect the individual’s needs and personality. The radiator cover in the bedroom was rusty and is in need to repair or replacement. A large hole was apparent within the partition wall. Staff members have made an effort to disguise the hole but this must be repaired appropriately. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 18 The shower room also contains a wash hand basin and a toilet. The toilet seat has been replaced but the old seat was propped in the room must be removed. The room was reasonably clean but is in need of redecoration. A number of walls on the ground floor of the home were dirty and in areas cobwebs were present. The carpet in the hallway was stained in areas, although staff are committed to cleaning/shampooing the carpet on a regular basis, staff stated that it “doesn’t remain clean for long”. The registered provider should consider whether the carpet should be replaced with a washable covering whilst maintaining a comfortable home for the residents. A large comfortable lounge area is available for all household members use. An additional lounge/activity room is available. A new kitchen has been installed and provides a clean place to prepare and cook meals, although painting and decorating needs to be completed. The dining room allows people to eat together with staff support. The decoration and cleanliness of the dining room is of a reasonable standard although the wall lights need to be repaired or removed and replaced. Residents’ bedrooms contained belongings that reflect the individual’s needs and personalities. Maintenance work to a bathroom at the top stairs has not been completed, brackets on the wall need to be removed and retiling needs to be completed. The brackets present a risk of injury to residents and must be removed. The bathroom is currently being locked when not in use. A garden at the rear of the property provides adequate shared space for all residents. Residents and staff are responsible for the cleanliness of the home. The home is reasonably clean. The cleanliness of the home should be monitored to ensure the health and safety of residents. 61 Adkin Way DS0000013060.V303966.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 The quality of the outcomes in this area is poor. This judgement has been made using available evidence including a visit to the service. The high usage of agency staff does not ensure consistent support that meets resident’s needs. Inconsistency in staff knowledge and competence does not ensure the protection of residents. Incomplete recruitment records do not ensure the protection of residents. Staff are offered and complete appropriate training to meet the needs of residents, although records held at the home are not up to date. EVIDENCE: Four staff members were on duty at the time of the inspection; only one person was a permanent member of staff. The remaining three staff were employed by an agency. Two of the agency staff had worked at Adkin Way previously and were aware of residents needs. One agency staff member had been introduced to Adkin Way on the day of inspection. The staff member confirmed that the Adkin Way staff member had provided a complete and professional induction at the start of the shift. The agency staff member described that the support needs of all residents were clearly explained including how to respond to any challenging situations. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 20 A staff member who came on duty in the afternoon later contradicted the information provided at induction regarding one individual. The agency staff member stated “There was a bit of inconsistency in what people told me about X…it was a bit confusing…you go with what people initially tell you and then someone changes it.” This raises concerns especially in light of a recent incident where a lack of consistency resulted in a serious allegation regarding one household member. Comments received from a clinician regarding the incident highlighted that, “There is inconsistency in managing boundaries with the individual, inconsistency in staff knowledge and understanding and inconsistency in management support therefore the monitoring of staff competency in how things are dealt with cannot be undertaken.” The home currently has 5 vacancies for support staff resulting in a high usage of agency staff. A resident’s care management assessment clearly states that, “X finds a high staff turnover difficult and when staff are stressed this causes X to become anxious.” The recruitment of new staff is ongoing, the manager acknowledging that it is important for residents to be provided with consistent support. Whilst the agency staff used maybe consistent the recent incident has clearly highlighted the need for permanent staff to be at the home. The home manager is due to report to the outcomes and actions following the incident in due course to the CSCI. The inspector viewed staff records chosen at random for four members of staff. Access to the records was initially restricted as only the registered manager had access to the filing cabinet. The manager attended a meeting at the home within the inspection; the inspector was then allowed to view the records. The previous inspection highlighted major shortfalls within the records. Improvement has been made. Records now include application forms and two written references although medical declarations were still missing from the files. No Criminal Records Bureaux (CRB) disclosures were available. No written declaration from the United Response human resources department regarding satisfactory CRB disclosures being obtained before staff started work was available. Photocopied photo ID remains on staff files. Again the inspector was unable to recognise individuals from this. Requirements regarding recruitment information have been made on numerous occasions. Whilst the manager of the home has made some progress in ensuring that the correct information is held at the home it is clear that further work is needed. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 21 The registered manager must ensure that all aspects of the regulations regarding the employment of staff are met. All information and documents in respect of staff members, which are required by regulation in respect of staff, must be kept in the home and made available for inspection. Training records were seen within staff records. The manager stated that training records are not up to date but would be reviewed an updated in the near future. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The quality of the outcomes in this area is poor. This judgement has been made using available evidence including a visit to the service. The management and conduct of the home is inconsistent and lacks boundaries for the safe support of residents. The quality of the service is monitored regularly with actions required. Health and safety checks are conducted appropriately. EVIDENCE: Previous inspections have highlighted shortfalls in the management and conduct of the home. Numerous requirements remain from previous inspections and have not been fully met or addressed. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 23 A deputy manager has been recently employed at the home due to the registered manager having a number of management commitments within United Response. The serious nature of a recent incident has highlighted the inconsistency in support for residents. The registered manager has neglected to ensure that all requirements are fully met by the identified timescales and has not ensured that consistent support has been offered to residents, therefore not fulfilling the legal responsibilities expected of a registered manager. Staff have clearly made considerable effort to provide a consistent service but have been undermined by the lack of a full compliment of permanent staff. The local authority provides ongoing monitoring of the quality of the service. A comprehensive report been produced with the outcomes being generally positive. Regular unannounced visits are made to the home by a manager within United Response to assess the quality of the service. The inspector welcomes the recent input from a Director within United Response to review and evaluate the quality of support offered. Health and Safety records viewed were up to date. 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 24 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 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X X 1 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 1 X 3 X X 3 X 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 25 YES 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 YA8 Regulation 15 Requirement The registered manager must ensure there is written evidence that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. Staff must ensure there is written evidence that service users have been supported to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. The registered manager must ensure there is written evidence to show that the daily routines and house rules must promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). The registered manager must DS0000013060.V303966.R01.S.doc Timescale for action 30/09/06 2. YA12 14 30/09/06 3. YA16 4 30/09/06 4. YA34 17 31/08/06 Page 26 61 Adkin Way Version 5.2 ensure that all aspects of the regulations regarding the employment of staff are met. This includes all information and documents in respect of staff who work in this home required by regulation are kept in the home is available for inspection 5. YA9 13 (4) (b & c) The registered manager must ensure that risk assessments are written and reviewed appropriately for the protection of residents. The registered manager must ensure that all information is held confidentially. The registered manager must ensure that the home is maintained and cleaned to a good standard to ensure the safety of residents and staff. The registered manager must ensure that the staff team provide continuity of care to meet resident’s needs. 31/08/06 6. 7. YA10 YA24 YA30 12 (4) (a) 23 (2) (b) & 31/08/06 31/08/06 8. YA33 18 (b) 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 61 Adkin Way DS0000013060.V303966.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!