Inspection on 14/05/08 for 82 Chaucer Road

This inspection was carried out on 14th May 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

82 Chaucer Road 12/01/07

82 Chaucer Road 20/02/06

82 Chaucer Road 01/12/05

82 Chaucer Road 19/10/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 82 Chaucer Road Bedford Beds MK40 2AP Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 14th May 2008 11:25a 82 Chaucer Road DS0000060926.V364261.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 82 Chaucer Road DS0000060926.V364261.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. 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 82 Chaucer Road Address Bedford Beds MK40 2AP 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) 01234 216319 01234 346362 elaine_holliman@msn.com Caretech Community Services Limited Mrs Elaine Louise Holliman Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Number of places: 8 Age: 18-65 years Category: All persons admitted to the home must have Learning Disabilities as their primary assessed need. No service users with additional physical disabilities shall be admitted, unless it can be demonstrated that the home can meet their needs by way of accessible private and communal space and appropriate aids/adaptations. 12th January 2007 Date of last inspection Brief Description of the Service: 82 Chaucer Road was first registered in June 2004 as a care home for up to six adults with learning disabilities. Caretech Community Services Limited who provides a number of homes for people with learning disabilities nationwide owns this home. The stated purpose of the home is to provide care and support to people who have diverse needs associated with their learning disability, such as behaviour that challenges needs on the autistic spectrum and people who require alternative communication systems. The home is not suited to people with mobility problems although ground floor accommodation is available. The home is a refurbished Victorian villa in a residential area on the west side of Bedford. Accommodation comprises of a large lounge, dining room/conservatory, kitchen, laundry room, and office on the ground floor. All bedrooms are for single occupancy and have en-suite facilities. There are bathing and toilet facilities on both floors. The home is now registered for 8 beds and has additional space for the visitors. The weekly and gross service cost is around £1,450/- per service user. 82 Chaucer Road DS0000060926.V364261.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 is the report of the unannounced inspection carried out on 14/05/08 by Pursotamraj Hirekar over 8 hours 25 minutes. The registered manager and the deputy manager coordinated the inspection. The method of inspection included study of care plans, risk assessments, staff deployment duty rota, staff profiles, relevant care delivery documents, discussions with staff and service users, observations of staff and service users’ interaction and partial tour of the building. Letter and documentary evidence received from the registered manager, in response to the feedback given on inspection, annual quality assurance assessment (AQAA) – provider’s self-assessment received is included for analysis and preparation of this report as well. What the service does well: What has improved since the last inspection? What they could do better: The registered manager must ensure that each individual service user changing needs are reflected in the care plan and reviews carried out to evidence progress made. The registered manager must ensure that the service users are not placed at risk of self-harm when accessing the community or living at the home. 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 6 The registered manager must ensure that the health action plans are reviewed at appropriate intervals and changes reflected in line with the information as prescribed on the MAR sheet. The registered manager must ensure that all staff working at home has appropriate safeguarding training to protect service users from any form of neglect or abuse. The registered manger must ensure that service users live in a safe and comfortable environment through appropriate building maintenance. The registered manager must ensure that all agency staff working at the home has statutory checks, appropriate qualification and training, which match the assessed needs of the service users. The registered manager must arrange fire tests and drills are carried out at appropriate intervals to ensure service users health, safety, and welfare are promoted protected at all times. The registered manager should arrange the Statement of Purpose and complaints procedures to the individual service user to reflect the current information and enable prospective and existing service users have awareness and understanding. The registered manager should arrange written contract statement detailing the terms and conditions for all the service users. The registered manager should evidence consultation with individual service users and structure leisure activities that meet their choices and time. The registered manager should ensure that the complaints received and resolved records are updated. The registered manager should ensure that assessment of all COSHH related products are reviewed and recorded appropriately. The registered manager should ensure that all service users have a safeguarding procedure in an appropriate format and style that they understand. 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. 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some of the information about the home was not up to date or available in a format that the people who use the service could understand. EVIDENCE: Information about the home that is contained in the statement of purpose and complaints process made available to people living in the home did not reflect the current information and was not in an easy read style. This is given to people when they move to the home as part of the admission process. During the inspection feedback session the registered manager stated that the ‘Statement of Purpose’ is being updated to include pictures, signs and symbols. The care of one person who is new to the home and has limited verbal communication was tracked. The care file contained a comprehensive preadmission assessment carried out by the registered manager before the admission to the home. The assessment gave sufficient detail to ensure that the staff are able to meet care and support needs of that person. The individual written contract statement detailing the terms and conditions were not provided on this inspection. The new person appeared to have settled in well. 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s independence is promoted and they are supported to make individual decisions in all aspects of their life and choice of lifestyle. However, people’s changing needs are not always reflected in the care plan. EVIDENCE: 2 service users were case tracked on this inspection. The various care documents presented included risk assessments, behaviour management plans, person centred plans, health action plans, specific programme plans, person centred plan reviews, daily service records, and social diary. These documents outlined the individual need of the person with regard to their personal care needs, support, health care, daily routines, social and cultural interests and safeguarding. The information was holistic and in relation to their choice of lifestyle and interests from their view. However, the written guidance that was available to help staff to provide the right level of support in relation to the changing needs of one person who has 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 10 a history of unpredictable and challenging behaviour was not sufficient. (please refer: personal and health care support outcome group of this report for details). For another person the 6 weekly report dated26/11/07 noted agreed actions that included joining a ramblers club, attend a local church service, gain independent living skills and a holiday. There was little evidence of the progress of the agreed actions, and the care plan did not reflect how the agreed actions would be implemented apart from recording as ongoing objectives. In response to the feedback during the inspection process the registered manager had carried out a review, on 16/05/08 and a copy was sent to the commission that recorded what progress has been made on each of the actions agreed. Observations were made of how people communicated with the staff for assistance and support. The staff on duty said people make their own decisions or are supported through conversation to make their own decisions. Observations made indicated the relationship between people living a the home and staff is relaxed, friendly and polite, showing respect to each other when they are talking or expressing a view. Some people can access social and community activities locally. Others have their daily routines; going to their place of work or day centre. On person had detailed hourly activities throughout the day. The information received from the registered manager before the inspection stated that people’s changing needs and goals are continuously reflected in the care plans, learning new skills and encouraged to be responsible for their home. The improvements identified relate to continue to monitor and review person centred plans. 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are consulted or listened to regarding the choice of daily activity and feel in control of their lives. EVIDENCE: Staff said people moving to the home are supported to continue participating in daily social and community activities. Information about individual daily, social and community activities are detailed in the assessment and included in the care planning. Through discussion with people living at the home both spoken and using gestures, it was clear that they continued to participate in daily activities ranging from the day services to going out socially and can choose how to spend the evening and weekends. Activities and daily routines were not always consistent with the interests recorded in the individual care plans. For example, one service user was waiting in the lounge to go for a music therapy 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 12 at 1.45pm and a staff member informed her that the music therapy session time had now changed to 11.00am, she was disappointed with late information reaching her. Also, all the service users were scheduled for art & craft session this PM. However, in practice this was not feasible for all the service users to attend an art & craft session at the same time. The registered manager needs to revisit the daily activity of each individual service user and in consultation with them structure in such a way that each one of them has an opportunity to engage in a meaningful activities without any hindrances. Staff have received training in preparation and safe handling of food. Staff said they always encourage people to choose the meals, and if necessary showing the food in the box to people with limited verbal communication. One person said; “I did all the shopping for myself and I do the meals myself ”. People indicated they felt in control of their life at the home and were not restricted in what they did. A couple of people said they do their own shopping in relation to personal toiletries and food shopping. Personal relationships and friendships are encouraged and staff said they give support and advise where necessary. Staff demonstrated a good understanding of the people they key work, recognising if they are anxious or unhappy, and how to approach them. One person spoke at length about their family and her visit to Canada. The information received from the registered manager before the inspection further supported the discussions with people and records viewed. The ethos of the home to promote independence, rights and choices is clearly evident by the way people live, make decisions, have an active and full lifestyle in a homely environment. 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are met and their independence is promoted and respected. However the information for one person needed further development. EVIDENCE: People’s personal and health care needs are detailed in the individuals care plans and in general staff have guidance in relation to the level of support required, if any. However, the written guidance that was available to help staff to provide the right level of support in relation to the changing needs of one person who has a history of self harm, challenging and unpredictable behaviour was inadequate. For example, this person went on a trip to town, accompanied by an agency worker, this was only his 3rd shift in the home, and there was no evidence of his training in safeguarding vulnerable adults, non violent crisis intervention and epilepsy. Also, risk assessments have not been reviewed in response to the recent incidents regarding safety self-harming, and the levels of support required. This was discussed with the registered manager during the feedback of the inspection process. Following this inspection the registered manager 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 14 developed and supplied to us a copy of the risk assessment for escorting the person in the community, to keep them safe, to manage and minimise any risk from self-harm and staff guidelines dated 16/05/08. People indicated that their privacy, dignity, and rights are respected and this was further confirmed from the observations made during the visit. People said they were not restricted and able to continue living their lifestyle of their choosing. People also said they maintain contact with family and friends, having the use of a telephone in the home. Care plans detailed emergency contacts and health care professionals involved in their care. Health action plans have been prepared in an appropriate format that enabled people with communication difficulties to understand. These health action plans have been reviewed and health care professional appointments scheduled were necessary, this was supported by the evidence from the record of health appointments which included GP, speech therapy, psychiatry, optician, dentist, sexual therapist and psychologist. Trained staff administers medication and training records confirmed this. Medication is stored in a locked cabinet. The medication for two people was checked. One service user’s medication prescription on the health action plan did not match with the prescription on the MAR sheet. For example, chlorpromazine 25 one twice a day was prescribed on the MAR sheet whereas, the health action plan recorded once daily. Paracetomal was prescribed on the health action plan but there was no information on the MAR sheet. Also, Betamethasane valerate scalp application was prescribed on the MAR sheet with no information on the health action plan. This information was shared with the registered manager during the inspection feedback session, and in response the registered manager confirmed to us in writing following our inspection that, these documents have been reviewed on 16/05/08, and staff have been informed. 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All service users do not have safeguarding procedure in an appropriate format and style that would enable them to understand. All staff has not received appropriate safeguarding training to protect service users from any form of neglect or abuse. EVIDENCE: The agreed multi-agency procedure for safe guarding adults was available at the home. These are not set out in an easy read style or included in care files. In response to the inspection feedback session, the registered manager confirmed in writing to us that, there is currently on-going work regarding the development of the support plans which is due to be piloted shortly. Meanwhile by June 7th a pictorial form of this information will be made available for everyone. Information received from the registered manager before the inspection stated that all complaints are investigated within 28 days. The home has received 2 complaints since the last inspection and resolved within 28 days. However, it was found on this inspection that, the complaint log record showed all complaints received were resolved, but no date was recorded, to show when these complaints have been resolved. The home had made 3 safeguarding adults referrals; of which 2 safeguarding adults’ referrals have been 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 16 investigated and 1 referral has been made to the Protection of Vulnerable Adults List. As part of this inspection, a thematic probe on safeguarding was carried out. In which specific questions were asked of the registered manager, staff, and people living at the home. The registered manager demonstrated a good awareness of her role, responsibility, policy, and procedures required to follow in relation to any allegation or suspicion of abuse. The registered manager was confident to whistle-blow poor or bad practice and make appropriate referrals. The home had permanent and agency staff. 2 permanent staff and 2 agency staff were spoken to on this inspection it was evident that the permanent staff demonstrated good awareness of their role, responsibility, and procedures to follow in relation to any allegation or suspicion of abuse. The permanent staff were confident to whistle-blow poor or bad practice. The permanent staff confirmed that the deputy manager or the registered manager is available at all times should any concerns arise. However, the 2 agency staff had little understanding of safeguarding of vulnerable adults and procedures to follow (please refer staffing outcome group of this report for additional information). In response to the inspection feedback session, the registered manager confirmed in writing to us that, she had scheduled for agency staff training on safeguarding adults. 3 people spoken to on this inspection appeared to be aware of what to do when they are not happy about. One person said ‘ I always speak to staff or the manager’. 82 Chaucer Road DS0000060926.V364261.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 good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean and tidy environment without any offensive odours creating a homely environment. However records of hazardous substances should be developed. EVIDENCE: The home is clean and tidy in appearance and suits the lifestyle of the people living there. The lounge decorated and furnished with domestic furniture that compliments the décor. Individual bedrooms are furnished with bedroom furniture and which had been personalised with photographs and ornaments that reflected their interests and hobbies. One person was proud of showing their aquarium. In the meeting of 27/04/2008, one person had reported that her bedroom roof leaks, when it rains heavily. We saw evidence of the damp patch on the ceiling of her bedroom. In response to the inspection feedback session, the 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 18 registered manager confirmed in writing that an urgent memo had been sent on the 16/05/08 to the company’s maintenance estate manager. There was not enough evidence to suggest that COSHH – powders, liquids, spray, hazardous substances assessments have been carried out regularly and appropriate records maintained. This was reported to the registered manager during the inspection feedback session. The registered manager confirmed to us in writing that these have been reviewed on the 16/05/08. The assessments would be carried out now every six months or when new products are purchased and introduced, and recorded appropriately. The registered manager had also planned to discuss this in the 21/05/08 senior support staff meeting. The home had decorated 3 people’s bedrooms, kitchen, lounge and quiet room since the previous inspection. The home also had plans to decorate the stairs and landing, have blinds and aircon in the conservatory. 82 Chaucer Road DS0000060926.V364261.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 adequate. This judgement has been made using available evidence including a visit to this service. Service users are protected by company staff recruitment, training, and supervision. There was no evidence to support that the agency staff have appropriate statutory checks, qualifications, and training, which match with the assessed needs of the people living at the home. EVIDENCE: The interaction of staff with the service users was good; there was a good rapport between everyone. Both verbal and non-verbal communication used was good and promoted a good understanding. The company had good recruitment procedures, having staff appointed upon receipt of two satisfactory references, Protection of Vulnerable Adults (POVA) first check, and Criminal Records Bureau (CRB) check. All the staff records were held centrally and staff profiles were maintained at the home for the permanent staff. However, the 4 agency staff that was working at the home had no such evidence to support their recruitment. The information received from the registered manager before this inspection stated 80 of the agency staff working toward NVQ level 2 or above. On this 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 20 inspection 4-agency staff training, qualification and qualification was checked. None of these 4 staff had enough awareness and understanding with regard to safeguarding adults, challenging behaviour and non-violent crisis intervention. On the day of inspection it was found that, one service user who has challenging needs, a history of self harm and unpredictable behaviour was sent on a trip to town, with an agency worker, this was only his 3rd shift in the home, there was no evidence of his training in safeguarding vulnerable adults, non violent crisis intervention and epilepsy (for more details please refer to the section on personal and health care support). However, the 2 permanent staff spoken to demonstrated enough awareness and understanding of safeguarding adults, non-violent crisis intervention and challenging behaviour when service users react in a given situation. The registered manager in response to the inspection feedback session confirmed in writing dated 16/05/08 following this inspection that all the relevant records for all the agency staff are now in place. All providers of agency staff have been informed of requirements that staff without relevant evidence of qualification, checks, and training will not work at the home. Staff confirmed they receive supervision. The minutes of the last team meeting was available and showed how information is shared with staff and concerns raised by staff are addressed in the best possible way. 82 Chaucer Road DS0000060926.V364261.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 good. This judgement has been made using available evidence including a visit to this service. Service users and staff benefit from a well managed home to promote independent living and a quality of life. However health and safety records must be properly maintained. EVIDENCE: The registered manager is working towards a national vocational qualification (NVQ) 4 in care, which she plans to complete by July 2008. The registered manager confirmed there are clear roles and responsibilities in relation to the management of the home and staffing. Staff were confident that either the deputy manager or the registered manager would be available if there was an emergency. Meetings for staff and meetings for people who live in the home are held to review and identify any improvements that are needed. People can speak with staff at anytime as well. 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 22 As part of the quality assurance system 15 questionnaires were sent to people’s families and key stakeholders of whom 6 have been returned with feedback. The registered manager mentioned that the feedback has been analysed and put through the maintenance department for the improvement of the premises. The information received from the registered manager before the inspection said that the home’s policies, procedures, and code of practice were updated, reviewed, and shared with the staff. The home had a programme of servicing and testing of equipment; gas and electrical testing and carries out regular fire tests and drills. However, There have been some gaps identified during the inspection process, with regard to fire evacuation drills, fire extinguisher record, and fire alarm. This was shared with the registered manager during the inspection feedback process. The registered manager confirmed in writing to us following this inspection that fire checks and subsequent written recorded evidence of the checks have been recommenced from 15/05/08. The registered manager will investigate the reason why these checks have been not carried out and discuss in the staff meeting scheduled for 21/05/08. The registered manager further said that a checklist has been devised to enable the registered manager or deputy manager to record that spot checks have been carried out. 82 Chaucer Road DS0000060926.V364261.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 2 2 3 3 X 4 X 5 2 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 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 2 X 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The registered manager must ensure that each individual service user changing needs are reflected in the care plan and reviews carried out to evidence progress made. The registered manager must ensure that the service users are not placed at risk of self-harm when accessing the community or living at the home. The registered manager must ensure that the health action plans are reviewed at appropriate intervals and changes reflected in line with the information as prescribed on the MAR sheet. The registered manager must ensure that all staffs working at home had received appropriate safeguarding training to protect service users from any form of neglect or abuse. The registered manger must ensure that service users live in DS0000060926.V364261.R01.S.doc Timescale for action 30/06/08 2 YA19 12 (1) 15/06/08 3 YA19 13 (2) 15/06/08 4 YA23 13 (6) 30/06/08 5 YA24 23 (2) (b) 15/06/08 82 Chaucer Road Version 5.2 Page 25 a safe and comfortable environment through appropriate building maintenance. 6 YA32 17 schedule 4 (6) The registered manager must ensure that all agency staff working at the home has their profiles available for inspection at all times. The registered manager must arrange fire tests and drills are carried out at appropriate intervals to ensure service users health, safety, and welfare are promoted protected at all times. The registered manager should evidence that all the agency staffs’ statutory checks have been carried out prior to their employment. The registered manager must ensure that all agency staff has had appropriate qualification and training prior to their working with people using services with challenging needs. 15/06/08 7 YA42 23 (4) 15/06/08 8 YA34 19 15/06/08 9 YA35 18 15/06/08 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 Refer to Standard YA1 Good Practice Recommendations The registered manager should arrange the Statement of Purpose and complaints procedures to the individual service user to reflect the current information and enable prospective and existing service users have awareness and understanding. The registered manager should arrange written contract statement detailing the terms and conditions for all the service users. DS0000060926.V364261.R01.S.doc Version 5.2 Page 26 2 YA5 82 Chaucer Road 3 YA14 The registered manager should evidence consultation with individual service user and structure leisure activities that meet their choices and time. The registered manager should ensure that the complaints received and resolved records were updated. The registered manager should ensure that assessment of all COSHH related products are reviewed and recorded appropriately. The registered manager should ensure that all service users have safeguarding procedure in an appropriate format and style that would enable them to understand. 4 5 6 YA22 YA24 YA23 82 Chaucer Road DS0000060926.V364261.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 82 Chaucer Road DS0000060926.V364261.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. 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