Inspection on 10/06/08 for 63-65 Bardsley Drive

This inspection was carried out on 10th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

63-65 Bardsley Drive 27/07/09

63-65 Bardsley Drive 13/06/07

63-65 Bardsley Drive 18/10/05

63-65 Bardsley Drive 19/04/05

63-65 Bardsley Drive 02/09/04

63-65 Bardsley Drive 06/04/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 63-65 Bardsley Drive Farnham Surrey GU9 8UQ Lead Inspector Vera Bulbeck Unannounced Inspection 10th June 2008 11:40 63-65 Bardsley Drive DS0000013525.V366190.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 63-65 Bardsley Drive DS0000013525.V366190.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. 63-65 Bardsley Drive DS0000013525.V366190.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 63-65 Bardsley Drive Address Farnham Surrey GU9 8UQ 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) 01252 727148 zoe.measures@tactsouth.org Thames and Chiltern Trust Ltd Post vacant Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (1) of places 63-65 Bardsley Drive DS0000013525.V366190.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be 35-65 YEARS One of the persons accommodated may be within the category (MD) in addition to being within the category (LD) There must be one to one support to the named service users 24hours (including `sleeping nights` during his stay at the home. 13th June 2007 Date of last inspection Brief Description of the Service: 63/65 Bardsley Drive has been developed from two independent semi-detached houses to an integrated establishment whereby some of the facilities are shared. It provides accommodation for 3 adults with learning disabilities. The house is located in a quiet residential area and within walking distance of Farnham town centre. The home has its own transport to support service users to access the wider community. There is off street parking at the front of the property, for two vehicles. The bedrooms are sited upstairs in both halves of the house. In addition, the ground floor area in both houses has a kitchen/diner and comfortable sitting room. The rear garden of the house is made up of one large patio area, with garden furniture. This is used as additional communal area, particularly in the summer months. Age range of persons accommodated 18-65years. The weekly fees range from £1,063.50 - £1,751.08 the fees do not cover personal items, hairdressing, holidays and outings. 63-65 Bardsley Drive DS0000013525.V366190.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced visit formed part of a ‘key’ inspection and was carried out by Vera Bulbeck, Regulation Inspector. The inspection process was over 7 hours and 20 minutes. The Registered manager has left 63-65 Bardsley Drive and the acting manger now in post was not available on the day of inspection. Support workers were involved in the inspection process. The site visit took into account detailed information provided by the previous manager and any information that CSCI has received about the service since the last inspection. The home received a copy of a letter addressed to social services praising the home, from the psychiatrist with the local community health team. This was seen by the inspector on the day of the site visit. A tour of the premises took place. On the day of this visit the inspector spoke with the three service users and two in great detail, and three staff on-duty. The home had completed an annual quality assurance assessment (AQAA) and service users’ care plans, staff recruitment and training records, menus, health and safety check lists, activity records, policies, procedures, medication records and storage were all sampled on the day of this visit. The Commission would like to thank the service users and staff for their time, assistance and hospitality during this visit. What the service does well: The staff work hard to ensure that service users’ needs are appropriately assessed and that their care is planned to ensure that these needs are met, whilst encouraging and enabling service users to maintain their independence where possible. Service user’s spoken with expressed their satisfaction with their quality of life at the home. Comments received from service users included: “I like it here, and the staff are very good”. All interactions observed between the staff and service users evidenced that the home has a close and caring staff team. 63-65 Bardsley Drive DS0000013525.V366190.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Six requirements have been made as a result of this inspection and four recommendations of good practice. A registered manager needs to be in post and the home needs to have a quality monitoring system in place to ensure the home is managed effectively. The record keeping in the home needs to improve. At the time of the inspection it was difficult for the staff to find several documents. Staff training needs to improve and records need to be available. Staff recruitment files need to be implemented as detailed in the Care Homes Regulations 2001 amended version, Schedule 2. This includes staff should not be working in the home without a POVA first check and a Criminal Record Bureau (CRB) Check. There is a need to implement a fire contingency plan to ensure staff are aware of where to go in the event of an emergency and if necessary to seek the advice of the fire officer. A number of records were not available on the day of inspection. Some areas need attention to the environment. The shed in the garden is used to store two bikes belonging to a service user, the shed is unsafe and moves when touched. 63-65 Bardsley Drive DS0000013525.V366190.R01.S.doc Version 5.2 Page 7 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. 63-65 Bardsley Drive DS0000013525.V366190.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 63-65 Bardsley Drive DS0000013525.V366190.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre-admission procedures at the home ensure that service users’ needs and aspirations are fully assessed prior to admission to make sure that their needs can be met. EVIDENCE: A member of staff advised the inspector that, on the first enquiry from a prospective service user or their representative, the service user or their representative would be invited to visit the home. Following the initial visit to the home, and if the service user wishes to continue, the manager will visit the service user and carry out a pre-admission assessment to ensure that the home can meet the Service user’s needs and wishes. Two care plans were sampled during this visit. In each case comprehensive pre-admission assessments had been carried out to ensure that the home could meet the service users’ identified needs. Service users living in the home have a copy of the Service User Guide in their rooms. The contents of these are gone through with help from staff. Taped versions are also available. 63-65 Bardsley Drive DS0000013525.V366190.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ individual plans are clear and comprehensive including details of needs and goals. They also incorporate known or indicated preferences. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: The home has a supportive care team and the staff demonstrated an in depth knowledge of each individual service users’ needs, abilities and preferences in how they wish their care to be delivered, resulting in one service user stating that they always receive the care and support they need. One service user commented, “I am very well looked after”. The care plans sampled during this visit were drawn up shortly after each service user’s admission to the home and included appropriate risk assessments. These care plans set out the actions, which need to be taken by 63-65 Bardsley Drive DS0000013525.V366190.R01.S.doc Version 5.2 Page 11 care staff to meet the health, personal and social care needs of the service users. It was noted that daily notes are kept that reflect the care given. These daily notes demonstrated that any changes or new concerns are promptly acted upon, although not always added to the care plan. The care plans are currently stored in the main office on a shelf. These records need to be stored appropriately in a locked facility particuarly the notes containing personal information. The care plan needs to be separate from confidential information. During the tour of the home staff were observed to always knock before entering the service users’ bedrooms and all interactions observed between staff and service users were seen to be caring and respectful. In the AQAA completed by the previous manager it states all service users have participated in their Person Centred Plans and help staff to continually update and monitor. Holidays have been changed to individuals choices, some activities have also been changed, and this was followed up from service users comments. Some of the service users requested to participate in training courses and have already attended Fire Safety. A Food and Hygiene course has been requested. 63-65 Bardsley Drive DS0000013525.V366190.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The service users have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Meals are well balanced and varied. EVIDENCE: The service users attend a number of activities. In the letter from the acting service manager it is stated that service users are supported to take part in the activities of their choice. Service users like to go bowling, one service user goes to the gym, another goes to a Thursday club and plays scrabble. One service user has two bikes and a member of staff goes riding with him. On the day of the inspection a service user had gone horse riding. One service user has just come back from a holiday in Wales with a member of staff. The inspector was shown the photographs of the holiday. Another service user was showing the inspector a brochure for a holiday in Lapland, he plans to go in 63-65 Bardsley Drive DS0000013525.V366190.R01.S.doc Version 5.2 Page 13 December, and this holiday has yet to be booked. Two service users enjoy playing music one plays the drums and another service user plays symbols and a tambourine. Two musicians visit the home to play on a weekly basis. The staff stated the music is great and the service users play well and service users and staff really enjoy the evening. Two service users have a key to their bedroom door and front door and the third person living in the home has a key to his bedroom door. It was noted that service users do not open their own mail, it was stated by a service user that the manager opens any correspondence. This practice is not acceptable and service users need to be given the opportunities for opening up their post. The acting service manager clarified after the inspection that all service users are on the electoral role. The inspector was informed that one service user likes to sit in the front of the car when travelling. A member of staff stated, if the driver happens to take a different turning the service user grabs the wheel. This practice could cause a potential accident and management need to review the current arrangements for the service user travelling in the front seat of the car. All three-service users are supported by staff to cook their own meals. They are encouraged to be as independent as possible. One of the service users offered the inspector a cup of tea, which he made and offered biscuits as well. Two service users have family contact and one has no family. An advocate is involved and visits the home on a regular basis. As stated in the AQAA the home offers the choice of pursuing interests and activities that are appropriate to the individual. All three service users enjoy three holidays a year, holiday’s have been changed to individuals choices. All service users access the community, for example the local library, concerts, gym, National Trust for walks and local pubs. Activities have also been changed; this was followed up from service users comments. Some of the service users requested to participate in training courses and have already attended Fire Safety. Service users have also requested a Food and Hygiene course. 63-65 Bardsley Drive DS0000013525.V366190.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was seen in care notes, to be provided, where needed, in a respectful and sensitive manner. Policies and practices are in place for the administration and management of medication. EVIDENCE: During this visit two care plans were sampled and it was seen that all health care needs were incorporated into the care plans. Records indicated and was evidenced that staff take prompt action to deal with any new health problem that may occur and care plans were specific with information for staff to follow when supporting service users to manage any long-term conditions. The lunchtime medication round was observed and the medication administration records, medication storage, policies and procedures were all sampled and found to be in order. The storage facilities were adequate medication was in a locked metal cupboard. However in the event of a service user requiring controlled medicines the homes does not have the appropriate 63-65 Bardsley Drive DS0000013525.V366190.R01.S.doc Version 5.2 Page 15 cupboard for storage. One service user is able to self medicate and keeps the blister pack, which the medication is stored in, in his bedroom. The staff signature list needs updating and two new members of staff need medication training. During this inspection, all interactions observed between staff and service users were polite and respectful. Staff never entered service user’s private rooms without knocking and awaiting permission to enter. All personal care was carried out behind closed doors. . 63-65 Bardsley Drive DS0000013525.V366190.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): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All required policies and procedures are in place to ensure that service users feel their views will be listened to. Systems are in place to protect service users from abuse and neglect. EVIDENCE: The home has a complaint’s procedure in place that is available to all service users, has been individualised to the home and is in picture format. This document needs to be displayed in a prominent position for service users to see and read. No recorded complaints have been made to the home since 2005. There has been one complaint made to the Commission for Social Care Inspection and this has been referred to Surrey safeguarding team to be investigated. There is a whistle blowing policy in place and the home have a copy of the latest Surrey Multi-Agency Procedure for the Protection of Vulnerable Adults. The member of staff stated all staff has received training or updates in the protection of vulnerable adults. However, there were no training records available to evidence this statement. Service users stated that they knew who to talk to if they were not happy. 63-65 Bardsley Drive DS0000013525.V366190.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): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and reasonably maintained. The home was found to be clean and hygienic and to meet service users’ individual and collective needs in a comfortable and homely way. There are some areas in the home that require attention. EVIDENCE: 63-65 Bardsley Drive is set in a quiet residential area close to local amenities and a short distance by car from Farnham town centre. The home consists of two semi detached houses with single bedrooms and each house has its own lounge and the kitchen also serves as the dining area. There is a bathroom and toilet in each house. The garden is communal for both houses reasonably maintained and in good weather is used frequently by the service users and staff. Laundry facilities are sited in each kitchen on the ground floor with a washing machine and tumble dryer suitable for the needs of the service users at the home. 63-65 Bardsley Drive DS0000013525.V366190.R01.S.doc Version 5.2 Page 18 Service users spoken with expressed their satisfaction with the accommodation provided at the home. The inspector had a tour of the home during this visit. The furniture and furnishings were seen to be of a good quality. A service user informed the inspector some of the furniture and furnishings in the lounge were purchased by the service users. Bedrooms were seen to be highly personalised to the individual service user’s wishes. All service users are provided with a key for their bedroom and the front door unless stated in their care plan reasons for not holding a key. The locks on bedroom doors need to be reviewed; the locks currently in use are used for all doors including the airing cupboard. This type of star lock is not appropriate and needs to be individualised for each bedroom. There are some areas that require attention in the home these include some cracks in the walls on the staircase. The radiators are without covers this could be a potential risk to a service user being burnt. The plug between the two freezers was broken and not securely fitted to the wall. The blind in the kitchen and lounge is broken and also a blind in a service users bedroom is broken and all need to be replaced. A service user informed the inspector the hot water tap in his bedroom is not working and needs to be attended to. The work surface in the kitchen is propped up with a book; this is a potential health and safety risk. The tiles in a bathroom are cracked and need replacing. The shed in the garden is used to store two bikes belonging to a service user, the shed is unsafe and moves when touched. On the day of this visit the home was found to be warm and bright with a homely atmosphere and a good standard of housekeeping apparent. 63-65 Bardsley Drive DS0000013525.V366190.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): 32, 34, 35 and 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staff training and recruitment programme needs to be followed in line with the Care Homes Regulations 2001, Schedule 2 Amended version. The majority of staff working in the home are competent and qualified to support service users. However, appropriate checks must be in place before staff are employed in the home. EVIDENCE: The staff rota evidenced that two member of staff are on duty and at specified times there are three staff on duty to enable service users to attend various activities. The rota needs to indicate and include the person in charge including the manager. At night there are two staff sleeping one in each house. However, it was noted that the staff do not have access to a telephone, the homes telephone is locked in the office and is not hands free. Therefore when staff are sleeping in do not have a telephone in the sleeping in room. The inspector discussed this with the Operations Director who confirmed this would be actioned and staff would be provided with a telephone for any emergencies. 63-65 Bardsley Drive DS0000013525.V366190.R01.S.doc Version 5.2 Page 20 Staff employed and staff recruitment files were sampled and one file was found to contain the relevant information and a new member of staff had only one written reference and two verbal references. There was not a POVA first check in place and there was no Criminal Record Bureau (CRB) check in place. This member of staff had been working unsupervised and collecting service users in the car from various activities. Staff must not be working in the home without these checks in place. A training plan needs to be in place so that staff training is kept up to date. One member of staff stated she has various certificates and these are kept in her own home. The inspector would advise a copy of the training records be held in the home to ensure training needs are being met and to enable these records to be sampled as part of the inspection process. One member of staff confirmed she is undertaking NVQ Level 3 training. The staff on duty confirmed supervision does take place however it is not very often. Staff supervision needs to be undertaken on a regular basis and should be at least six times a year. A member of staff on duty was not able to confirm if staff had been supplied with a copy of the General Social Care Council (GSCC) code of conduct and practice. 63-65 Bardsley Drive DS0000013525.V366190.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): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements in place on the day of inspection were not appropriate for the home to function to a good standard. The service users must be protected from potential harm and abuse. EVIDENCE: The registered manager left 63-65 Bardsley Drive and has been promoted by the company Thames and Chiltern Trust (TACT). The deputy manager has been promoted to acting manager and is currently managing the home and staff from her home. The inspector advised TACT Organisation management the arrangements need to be reviewed. The Operations Manager since the inspection has confirmed to the Commission, TACT are employing an agency 63-65 Bardsley Drive DS0000013525.V366190.R01.S.doc Version 5.2 Page 22 manager as an interim arrangement for two months. TACT needs to ensure the person appointed as the manager completes the registration process within three months. A member of staff informed the inspector that Service users’ views are sought on a regular basis. However, these records were not available. In a letter to the Commission from the acting service manager it is reported that regular service user meetings are held. The last was on the 1st May 2008 attended by the advocacy group. Monthly visits by a representative of the responsible individual take place as required. The organisation carry out a yearly survey, which seeks the views of service users, family, friends and other stakeholders in the community (i.e. district nurses etc.) Details of the survey were not available. The staff at the home carries out all necessary health and safety checks, with documentary evidence inspected of routine fire practices and evacuations. Fire equipment checks and daily checks of the fridge and freezer temperatures. The Fire risk assessment, needs to be undertaken on a regular yearly basis, was not available. There is also a need to implement a fire contingency plan to ensure staff would be aware of where to go in the event of an emergency, and if necessary to seek the advice of the fire officer for further information. The certificate for the testing for Legionella was not available. In the letter from the acting service manager it is stated that the service was informed by the Health and Safety inspectorate that such a test was not necessary. A risk assessment pertaining to this is on file. A number of records were not available on the day of inspection. All records need to be in place and should be available for inspection purposes. A number of policies and procedures need to be updated with a date of the next review to be included. In the AQAA completed by the previous manager it states the management and staff provide a safe and homely place for service users to live and to encourage people to live healthy, empowered and active lives. The team of support workers are highly motivated and training is high on the agenda. An open door management style is adopted and sharing of good practice is actively encouraged. The service holds regular service user meetings, operates an open door policy whereby service users can talk to their keyworker, deputy manager or manager. The management include service users in recruitment of staff. A format of questions have been incorporated into the interview process. 63-65 Bardsley Drive DS0000013525.V366190.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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X 63-65 Bardsley Drive DS0000013525.V366190.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. 2. Standard YA16 YA24 Regulation 12 16 & 23 Requirement Service users should open their own post. Areas needing attention: • Cracks in the walls on the staircase. • The radiators are without covers this could be a potential risk to a service user being burnt. • The plug between the two freezers was broken and not securely fitted to the wall. • The blind in the kitchen and lounge is broken and also a blind in a service users bedroom is broken and all need to be replaced. • The hot water tap in a service users bedroom is not working and needs to be attended to. • The work surface in the kitchen is propped up with a book; this is a potential health and safety risk. • The tiles in a bathroom are cracked and need DS0000013525.V366190.R01.S.doc Timescale for action 18/07/08 18/07/08 63-65 Bardsley Drive Version 5.2 Page 25 3. 4. 5. 6. YA34 YA35 YA37 YA42 19 18 8 17 & 13 replacing. • The shed needs attention. All staff must have appropriate checks undertaken before commencing work in the home. A training plan and staff training records need to be available in the home. The Organisation must apply for registration of a manager. All appropriate records should be available in the home including health and safety. • • A fire risk assessment, updated annually An emergency contingency plan. 11/06/08 04/07/08 10/09/08 04/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA10 YA24 YA34 YA36 Good Practice Recommendations The care plans need to be separate and confidential information should be stored in a locked facility. The locks on service users bedroom doors need reviewing. The manager needs to be identified on the rota Night staff should be provided with a telephone for emergencies in the sleeping in room. 63-65 Bardsley Drive DS0000013525.V366190.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 63-65 Bardsley Drive DS0000013525.V366190.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. 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!