Inspection on 04/07/05 for 61 Adkin Way

This inspection was carried out on 4th July 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

61 Adkin Way 04/01/07

61 Adkin Way 13/06/06

61 Adkin Way 21/11/05

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 Oxon OX12 9HN Lead Inspector Julian Griffiths Announced 4 July 2005 th 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 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 Stationary 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 H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 61 Adkin Way Address Wantage, Oxon OX12 9HN Telephone number Fax number Email 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 United REsponse Elizabeth Webb Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 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 is owned by a housing association. Service users are registered with a local GP practice and have access to specialist services as required. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which means that it was planned with the home in advance. However the home’s management did not complete and return a pre-inspection questionnaire, which provides valuable background information, before the inspection took place, as is usual practice. Neither did it send out to service users’ relatives and other interested parties the survey questionnaires supplied by the Commission, so that their views were not taken account of during the inspection and cannot be represented in this report. The questionnaire will be completed and the survey will take place after the inspection and will be taken account of at the next inspection, which will be unannounced. The inspector was in the home from 10.15am until 5.15pm on the day of the inspection. He spoke with service users, staff members and the manager, watched staff members at work and examined written records. Service users were confident and at ease with staff members, and staff members responded to service users with courtesy and respect, offering choices and promoting independence. Service users who were asked expressed themselves well satisfied with the home. The home is short of staff and relies heavily on agency staff to fill the gaps, and service users’ opportunities for activities, whilst improving, are still at a low level. What the service does well: The home provides information about the accommodation and services it provides to service users and prospective service users and their representatives. The home makes sure it understands prospective service users’ needs and wishes before they move in. Prospective service users have plenty of opportunity to get to know the home before they move in. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 6 Each service user has his needs and wishes set out in an individual written plan. Service users are enabled to make day to day decisions about their lives and routines. Service users are supported to take reasonable risks in order to enhance their independence and quality of life. Service users have opportunities to develop self-help and independent living skills. Daily routines promote service users’ rights, choice and freedom of movement. Service users receive personal support in the way they prefer and require. Service users’ healthcare needs are met. United Response provides staff with in-service training so that they can better meet the needs of service users. In general the health safety and welfare of service users are promoted and protected. What has improved since the last inspection? What they could do better: The way the Service User Guide is written needs to be more accessible to people using or likely to use the service. The contracts between the service users and the service providers are incomplete and unsigned. Service users have had little access to training, education or employment. Service users are enabled to access the local community, and to pursue some leisure activities but more and wider opportunities need to be provided. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 7 The home should continue to improve its recording of service users’ healthcare to enable their healthcare to be better monitored. The home needs to employ more staff so that it relies less on agency staff. The manager does not provide regular enough supervision to meet the needs of staff working in a demanding role. The home does not have a system for quality assurance which seeks and responds to the views of service users. Some aspects of health and safety management need to be improved. 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 H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 4 and 5 The home provides information about the accommodation and services it provides to service users and prospective service users and their representatives, but the format used needs to be more accessible to people using or likely to use the service. The home assesses prospective service users’ needs and wishes before they move in. Prospective service users have plenty of opportunity to get to know the home before they move in. The contracts between the service users and the service providers are incomplete. EVIDENCE: The home has produced a written Statement of Purpose. The inspector read this and found it to meet the required standard. It has also produced a Service User Guide. Much of the language in this document would not be understood by service users. It is recommended that the Service User Guide be reviewed to make it’s language and presentation more accessible to service users. The inspector advises that both documents be dated so that readers can see how up-to-date they are. Copies of both documents were displayed in the home. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 10 United Response has a written policy, seen by the inspector, which describes a thorough and appropriate assessment process. The paperwork from a service user’s pre-admission assessment was seen. This showed that a proper assessment had been carried out. It included an assessment and draft care plan drawn up by the service user’s care manager. The inspector saw a written plan relating to a prospective service user’s introduction to the home. This indicated a flexible approach based upon the individual’s needs and included some overnight stays and “as many day visits as needed”. An “Assured Tenancy Agreement” between a service user and the housing association which owns the premises was seen. The home manager said that all service users had one. This detailed the service user’s rights with regard to accommodation, equipment, physical services and day to day support. It was incompletely dated, signed by the then home manager on behalf of the service user and not signed at all by the housing association. It is recommended that such Agreements be signed by the service user, or someone representing their interests, and by a representative of the Housing Association. A service user’s record also contained a “charter” in the form of a statement of the rights and responsibilities of the service user and United Response as service provider. The example seen had not been signed by either party. It is recommended that the charters be signed by service users, or persons independent of the home acting on their behalf, and by the registered manager on behalf of United Response. The manager said that there was another contract between Oxfordshire Health and Social Care Department and United Response in respect of the services provided to service users, but this was not available for inspection. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 Each service user has his needs and wishes set out in an individual written plan. Service users are enabled to make day to day decisions about their lives and routines. Service users are supported to take reasonable risks in order to enhance their independence and quality of life. EVIDENCE: An example of a service user plan was seen. The format had developed and improved since the last inspection. Presentation was clear and the contents reflective of the person’s needs wishes and priorities. There was a clear and appropriate emphasis on ensuring that staff understood the service user’s communication and responded appropriately. There were detailed guidelines covering many other aspects of the service user’s life, and these were all signed by staff members in acknowledgement that they had read and understood them. The plan included specialist guidance in respect of preventing and minimising self-harm, but no restrictions on choice or freedom were noted and the manager confirmed that there were none. The manager 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 12 said that much of what was in the plan was based upon information and guidance provided by the service user’s close relatives. All planning documentation seen had been produced within the last 6 months. The manager said that plans were reviewed at least 6-monthly, and that every service user had a key worker. The manager said that as a matter of priority the home was moving to a system of person-centred planning called Essential Lifestyle Planning, and that she had received, and other staff were to receive, training in this regard. This is to be welcomed as it is likely to ensure that the whole service is demonstrably centred around the needs of each individual and any shortcomings are easily identified. The inspector saw service users being offered choices about how to spend their time, for example whether or not to go out, what activity to pursue, and that these choices were respected by staff. Records also reflected this. A risk assessment document showed that staff were encouraging a service user to take more control of his money. In a previous inspection a restriction on service users’ freedom was noted in the form of a front door alarm. The manager stated that this had been removed and that there were no restrictions on service users’ freedom. Service users were seen to access all parts of the house and garden freely during the inspection. The inspector saw United Response’s comprehensive and appropriate risk management policy, which included the statement: ”In United Response we use risk assessment both to facilitate and encourage service users to develop their skills as well as to react to hazards”. Examples of risk assessments were seen which supported this approach. They included service users going for walks, using the kettle and hob and other kitchen equipment, and carrying and using their own money. The home has a written procedure, seen displayed in the office, on what to do should a service user be missing from the home. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15 and 16 Service users have opportunities to develop self-help and independent living skills. Service users have had little access to training, education or employment. Service users are enabled to access the local community, and to pursue some leisure activities but more and wider opportunities need to be provided. Daily routines promote service users’ rights, choice and freedom of movement. The home promotes service users’ contacts with friends and relatives. EVIDENCE: The inspector observed that service users had complete freedom of movement within the communal areas of the home, including the kitchen. At the last inspection the inspector saw service users preparing food and drinks for themselves with staff support as needed. A service user told the inspector that he could do this. Individual guidelines seen in a service user’s plan were clear about enabling the service user to use his skills in everyday life. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 14 A staff member told the inspector that in the past a service user had been enabled to go to church every week, but that this had stopped, she did not know why. When asked, the manager did not know why either. The manager must ascertain from the service user whether he wishes to continue going to church, and if so enable him, so far as is practicable, to attend. The inspector saw no evidence that service users were attending any employment, training or education outside the home although one service user said that he enjoyed helping with gardening in the home’s garden. A staff member who spoke with the inspector said that she was investigating the opportunities available to service users at a local day centre. This sounded very positive. One service user’s plan included input from a psychologist which included the recommendation that he have a structured day in terms of activities. Staff who were asked said that there was no structure in place. In respect of another service user a staff member said that he could do so much more than he was doing at present, that he was supposed to have an opportunity to do something every morning, but didn’t at the moment. A staff member commented on how little activity was available to service users over the week ends, and another spoke of the opportunities that were missed because service users got up late in the mornings and had no structured day. Staff members said that the low level of activities had been discussed at a recent staff meeting. Staff members spoken to were unable to attribute a clear reason for lack of activities, although one suggested a general lack of motivation and another that additional staff would help. Another said that things had started to improve since staff had started to acknowledge the problem. Recent records sampled showed that some activities were taking place, for example local walks and drives, shopping and the occasional visit to a pub. Staff spoke of new initiatives such as regular planned outings to places of interest (the last one had been to Bath), dog walking, re-establishing a regular video library visit for one service user and hopefully the use of a local day centre. On the day of the inspection service users variously went out to the library and shopping, watched TV and listened to music, sang and danced. Other opportunities were offered but declined. Each service user has a “1:1 day” every week when they have the opportunity for doing their personal banking and shopping, to have lunch out, to change their bed and clean their room. The manager, as part of person centred planning, must take action to ensure that each service user has adequate opportunity to undertake activities suited to his needs, wishes and interests, including community based activity. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 15 Information provided by the manager, staff and records showed that all but one service user had close and continuing contact with their families, which included in some cases regular time away from the home staying with close relatives. A service user with no such contact retained friendship links with some ex-staff members of the home. Based on information from the manager’ about the frequency of contact this seemed somewhat tenuous, and a recent opportunity to attend a social function with these friends had been missed because of a diary mistake at the home. The manager said that she was intending to use the person-centred planning process to improve contact and relationships for this service user. Service users’ bedrooms are fitted with locks which could ensure privacy and security whilst enabling staff to have access in an emergency, however at the time of the inspection none of the service users kept their own key. The manager was unclear as to why this was. It is recommended that unless their assessed and recorded needs and wishes indicate otherwise, service users be enabled to keep and use a key to their bedrooms. The manager said that service users’ mail was given directly to them unopened. Staff members were seen to talk and interact with service users continually throughout the inspection. Service users were seen to exercise choice to be alone in their bedrooms and other parts of the house, including when this involved an element of assessed risk, or to be in company, to accept or decline activity opportunities and to change their minds. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 18 and 19 Service users receive personal support in the way they prefer and require. Service users’ healthcare needs are met. EVIDENCE: The example of a service user plan seen by the inspector indicated that the person’s choices and preferences about how he was to be supported were ascertained, and that staff were expected to know and respect them. Observation of, and discussion with, staff indicated that this was the case. Recorded routines around service users’ bedtimes and mealtimes were seen to be determined by their own wishes. At the last inspection a statutory requirement was made to improve the records kept with regard to service users’ healthcare so as to enable staff better to monitor individuals’ health needs. At this inspection a new system was seen to have been recently introduced, though the record seen had hardly been used yet and the manager indicated that it was something of a struggle to ensure that consistent recording by staff took place. The evidence was therefore gathered from other parts of the service user plan, diary entries and discussion with staff. These indicated that service users had been offered a health check with their GP within the last 12 months and that service users’ weights were regularly monitored. (These need to be recorded individually 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 17 within service users’ own records rather than all together on a piece of paper in the back of the diary.) There was evidence of service users receiving dental treatment and attending hospital appointments. There was documentary evidence of active and ongoing psychiatric and psychological services for a service user. At the time of the inspection a service user with an infection had visited his GP and been prescribed medication. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 18 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 standard(s) 22 and 23 The home listens and responds to concerns and complaints. The home takes action to ensure service users are protected from abuse. EVIDENCE: United Response has a very thorough written procedure, seen by the inspector, with which its staff are expected to respond to complaints within a defined period of time. The home records details of complaints and the action taken in response. The last complaint record (for a complaint received 10 months prior to the inspection) was seen by the inspector. It showed that the complaint had been quickly and fully responded to. United Response also has a procedure for service users to follow if they wish to complain. It is in simpler form and was seen to be displayed on the office wall and in a service user’s record. Details of the Commission were incomplete and out of date, and also details about the United Response staff to whom service users could make representations had not been completed. It is required that the procedure be completed in respect of these points. United Response has a good protection of vulnerable adults policy and a whistleblowers (“Challenging Bad Practice at Work”) policy which the inspector saw in the home. The Oxfordshire Multi-Agency Codes of Practice for the Protection of Vulnerable Adults were also available in the home. Staff training records seen showed that all staff had received training in adult protection (Prevention of Harm training). Documents associated with an abuse related incident showed that the home responded well to the incident and acted quickly to protect vulnerable adults from harm. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) No judgement was reached about these outcomes as none of the standards in this section were appraised. EVIDENCE: 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35 and 36 The manager is working to ensure that all employed staff have a basic qualification which demonstrates their competence to meet service users’ needs. The home does not employ enough staff so that it relies too heavily on agency staff. United Response provides staff with in-service training so that they can better meet the needs of service users. The manager does not provide regular enough supervision to meet the needs of staff working in a demanding role EVIDENCE: The manager said that there were 6 employed staff members at the time of this inspection, one of whom was qualified to National Vocational Qualification (NVQ) Level 2, two of whom had nearly completed NVQ Level 2, two of whom needed to start working towards NVQ Level 2 and one of whom was about to leave. The manager needs to ensure that at least 50 of the staff team have achieved NVQ Level 2 by 31st December 2005. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 21 The home relies heavily on agency staff to provide sufficient staff cover in the home. These staff are not recruited, supervised, trained or managed by United Response, and it appeared from discussion with them that they received their induction training for 61 Adkin Way from the manager of the agency, rather than from United Response staff. The home manager said that she estimated 50 of the staff working at the home to be agency staff, and that some shifts were composed entirely of agency staff. She cited this as a possible reason why some recording tasks did not get done. In order to maintain a consistently high standard of support it is required that the home employ more staff and reduce it’s reliance on agency staff. Records were seen which showed that employed staff received a structured induction training programme and Learning Disability Awards Framework foundation training, and that the manager took steps to ensure that this was completed. Staff training records showed that staff members received core and specialist training, including in the management of challenging behaviour, and including training to meet the very specific needs of one service user. Staff supervision records were seen which showed individual supervision meetings taking place at half the frequency specified in United Response’s supervision policy, and much less frequently than specified in individual staff members’ individual supervision contracts. It is required that each staff member receive individual supervision at least at the minimum frequency stated in United Response’s supervision policy (ie 6 times a year). Records showed that staff meetings were taking place every two months, with good attendance. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 and 42 The manager is working towards achieving a recognised qualification for care home managers. The home does not have a system for quality assurance which seeks and responds to the views of service users. In general the health safety and welfare of service users are promoted and protected. Some aspects of health and safety management need to be improved. EVIDENCE: The manager stated that she was working towards her NVQ Level 4 in Health and social care and the Registered Managers’ Award. The manager said that there was no formal mechanism for seeking the views of service users, relatives, friends and others about the service and responding to these, and no annual service development plan. There had been attempts 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 23 in the past to use service user questionnaires, and there had been a plan to begin regular consultation with service users’ close relatives, but neither of these was happening at the time of this inspection. There was evidence that for the most part, United Response had fulfilled its legal duty to visit and report on the conduct of the home at a minimum frequency of once in every month. However no report could be found for the month of January 2005 which casts doubt on whether a visit took place. United Response must take action to ensure that the home is visited, and a report on its conduct produced, at least once in every month. The inspector looked at records relating to health and safety at the home. Some very positive features were noted, for example a periodic audit by United Response’s health and safety manager, the most recent of which had taken place in January 2005, and the report of which found that health and safety was “greatly improved” and that all recommendations made at the previous audit had been acted upon. Also noted were records of regular checks on the home’s car, regular hot water temperature checks, regular checks on fridge/freezer contents, up-to-date electrical appliance testing, regular testing of the fire alarm system and staff training in health and safety, food hygiene, manual handling and 1st Aid. It was noted that the home’s gas boiler was overdue for servicing, that the Environmental Health Officer’s recommendation dated November 2004 that radiator covers be fitted to two radiators had not yet been addressed, and that staff fire safety training was taking place only once in every three years, instead of at least annually. It is required that these matters be addressed. 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x 3 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 3 2 2 2 3 2 x Standard No 31 32 33 34 35 36 Score x 3 2 x 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 61 Adkin Way Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 1 x x 2 x H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 25 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 11 Regulation 16(3) Requirement The manager must ascertain from a service user whether he wishes to continue going to church, and if so enable him, so far as is practicable, to attend. The manager, as part of person centred planning, must take action to ensure that each service user has adequate opportunity to undertake activities suited to his needs, wishes and interests, including community based activity. Service users weights must be recorded, where this is necessary, individually within service users’ own records rather than all together on a piece of paper in the back of the diary. The homes complaints procedure for service users must be amended to include the details of the persons to whom service users can make representations and with the name, address and telephone number of the Commission. It is required that the home employ more staff and reduce it’s reliance on agency staff. It is required that each staff Timescale for action 31/07/05 2. 12-14 16(2)(m) and (n) 30/09/05 3. 41 17(1)(b) 31/07/05 4. 22 22 31/07/05 5. 6. 33 36 18 18(2) 30/09/05 31/07/05 Page 26 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 7. 39 26(2) 8. 42 13(4) and 23(4) member receive individual supervision at least at the minimum frequency stated in United Response’s supervision policy (ie 6 times a year). United Response must take 31/07/05 action to ensure that the home is visited, and a report on its conduct produced, at least once in every month. Take action to ensure the gas 31/07/05 boiler is serviced at least annually, to ensure that the recommendation of the environmental health officer dated November 2004 is addressed, and that all staff members receive fire safety training at least every year. 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. Refer to Standard 1 4 Good Practice Recommendations It is recommended that the Service User Guide be reviewed to make it’s language and presentation more accessible to service users. It is recommended that Assured Tenancy Agreements be signed by the service user or someone representing their interests and by a representative of the Housing Association. It is recommended that service users charters be signed by service users or persons independent of the home acting on their behalf, and by the registered manager on behalf of United Response. It is recommended that, unless their assessed and recorded needs and wishes indicate otherwise, service users be enabled to keep and use a key to their bedrooms. 3. 16 61 Adkin Way H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Burgner House 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 H57-H08 S13060 Adkin Way V224354 140605 Stage 4.doc Version 1.30 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. 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