Inspection on 14/07/05 for 92 Wilcot Road

This inspection was carried out on 14th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

92 Wilcot Road 25/06/07

92 Wilcot Road 13/02/06

92 Wilcot Road 29/03/05

92 Wilcot Road 31/01/05

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

CARE HOME ADULTS 18-65 Wilcot Road (92) 92 Wilcot Road Pewsey Wiltshire SN9 5NL Lead Inspector Stuart Barnes Announced 14 July 2005 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. Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Wilcot Road (92) Address 92 Wilcot Road Pewsey Wiltshire SN9 5NL 01672 563914 01672 563914 staff@whct.co.uk White Horse Care Trust 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) Alison Burton Care Home 3 Category(ies) of LD Learning disability registration, with number of places Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31 January 2005 Brief Description of the Service: 92 Wilcot Road is a care home for three people with a learning disability some of whom were previously cared for in a nearby long stay hospital for people with a learning disability. The home is located in the small town of Pewsey. The service replicates principles of ordinary living and the house, which is semi detached, is indistinguishable from other houses in the street. All the bedroom accommodation is in single rooms and there is a range of communal space including an attractive patio and garden. The service is managed by the White Horse Care Trust, which has a number of similar care homes throughout Wiltshire and beyond. The aim of the service is to provide ordinary living that maximises independence. The home provides transport for accessing the local area and further a field. Service users can attend Marlborough day centre for day activities subject to the availability of places. Typically 2 people staff the home through the waking day. At night time one staff member ‘sleeps in’ and is expected to respond to any night time and emergency needs as they arise. Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection, which was by appointment, took approximately 8 hour’s. Twenty three standards were inspected out of a possible forty three, of which only 3 show a minor shortfall. Prior to commencing the inspection the inspector examined various pre inspection documentation supplied by the service. Comments cards were sent out to family members so they could provide their views of the service. The inspector spent time with all the service users and observed staff interaction with them. He also spent time talking to the staff on duty and met with the home manager and the Trust’s service manager. A range of paperwork was examined including care plans and assessment documentation. Service users showed the inspector their accommodation and talked about life in the home. What the service does well: What has improved since the last inspection? What they could do better: Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 6 Their continues to be a need to appoint more permanent staff. The service should request the fire safety officer to visit the service more often to report on the standards of fire safety. Consideration should be given as to how the service might facilitate service users getting payment for work they do outside the home. 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. Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 3 The service is good at assessing need and in planning how need should best be met. EVIDENCE: The inspector examined case documentation in respect of all 3 service users currently living at the home. The files contain relevant and detailed information about each person’s life history including their health needs, social care needs and associated assessment of any risk factors that arise. Risks and any resultant restrictions are well articulated in these documents. The areas covered in these documents are considered comprehensive and include specialist needs. For example one file states; “the service users will decide by pointing or selecting an item- staff must be patient when offering choices.” Another entry on the file states, “the person can give simple consents but not make complex decisions – when communicating emphasize key words, enhanced by gesture and speak clearly.” The files also show that staff routinely update the information and that this is done in a considered and professional manner. They also promote current best practice and continuity of care. There is a good balance in reporting on aspects of health, behaviour, leisure and day activities as well as any social and personal care needs. Support staff were observed to be using these documents as working tools to inform colleagues and others. The staff team is a good mix of age, experience and gender. Some of the current staff have known the people who live at the Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 9 home for many years. They understand the importance of consistency and they help make connections with past events. Records show that staff are properly recruited, selected and inducted in the work they do. Support staff praise the service for the amount of training they receive. Service users expressed through the use of gesture or monosyllabic responses their satisfaction with the care provided. They each conveyed that at least one staff member was special to them, caring and kind. This suggests the key worker system is working well. Examination of formal placement reviews confirm good satisfaction levels with the care provided. This is illustrated by one care manager stating, “(my client) likes the home, the staff and the other service users.” Service users were able to demonstrate to the inspector how they are involved in certain decisions. For example two service users indicated that they chose the decorations in their room. Another spoke about choosing a holiday venue. There is a good understanding within the service that the current group of service users have a range of complex needs. Short term care is not offered at this service. Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 The standard of care planning is considered very high and includes service users being actively encouraged and supported to make decisions about their lives. Risk assessment is well managed and well documented. EVIDENCE: All service users have a detailed care and support plan that includes detailed risk assessments. The plan covers; access to records, aspects of personal care, communication needs, consent, death and dying, health care, personal safety, mobility, spirituality, work and leisure, family contact, and risk. All plans have been updated at least once in the previous 6 months. Most more often than 6 monthly. There is evidence to show that apart from support staff other significant people can and do contribute to the care planning and review process. Examples include a family member, a care manager as well as the service user in attendance as well as a report from the day services provider. Any restrictions are included in the care plan. For example; “Limit alcohol to one drink (for health reasons)” or “person may make requests that are not always possible – i.e. want to go out in the dark to visit people.” In this example staff are instructed to keep a record of such requests and to act on them at a more appropriate time. There is a book that shows this happens. The description of any behaviours are non judgemental and focus on positives. Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 11 For example in one report it says “needs encouragement to dress properly” or, “...may display some adverse behaviours.” Another example shows sensitivity towards a request from the service users family by recording a wish that, “the service user is requested not to attend her mothers funeral due to the safety risks to the person and to others.” These unusual circumstances were discussed with the manager and they appear appropriate to the circumstances. Each service user has an allocated key worker and co-worker and the service will support service users to access an advocate if needed. Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16, and 17 Overall the service is good at meeting all the standards inspected in this section if taking into account assessed needs and capabilities. A feature of this (and previous inspections) is that service users compare the experience of living in this home and being part of the wider community very favourably. Staff work hard to support service users to access and be a part of their local community. Opportunities for paid work appear limited by geography and resources. The service is good at ensuring any routines and expectations focus on providing a consistent and caring approach that is in the service users best interest. EVIDENCE: All service users have the option to attend a local day centre that provides discrete services to people with a learning disability. Care plans and various case documentation also shows that current service users participate in a range of activities that include attending a local college of education and various out-reach networks. No current service user is receiving payment for any work they carry out. Service users report that they are learning new skills and that they get Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 13 opportunities for work and play. For example one person is supported to go horse riding, another is supported to go to an art workshop. Another is supported in developing and improving their life skills which include shopping, handling money, road safety and the use of transport. It was observed that one service user was taken out to purchase some clothing they needed. Another service user told the inspector that they recently visited the hairdresser – something records show they do regularly. Staff report that such visits are as much for a social need and to promote self worth as for styling. This illustrates that staff care about the person in the whole. Case files also show evidence of staff working positively and constructively with people who, on occasions, do not want to follow their programme. Support staff were heard telling service users about a local event that they thought might be of interest and getting some feedback on whether any one wanted to go to it. Staff report that service users are going out more and following their programme as a result of improvements in staffing. Records show all service users are registered to vote. According to the support staff and the manager the home enjoys good relationships with it its neighbours and that people who live in the home are generally well accepted by the wider community. Discussions with the manager indicate good awareness of how difficult it can be for families when a family member was placed in a long stay hospital, and moves into a care home. This is a service that works hard to support service users to maintain and develop their relationships with family members. Recent placement reviews highlight the efforts made. In one example there is evidence that shows that the support staff promote kinship and that they will involve family members in key decisions. Visitors can be seen in private. Feedback from one relative says they are always made to feel welcome when visiting. Case documentation shows that support staff take people who live at the home to visit any family and nearby and distant friends. Where appropriate this includes assessing any new risks or arranging extra staff cover. The nature of the service typically requires that such visits are planned rather than spontaneous and this appears proper in the circumstances. Case documentation shows that issues such as sexuality and intimate relationships are addressed according to each person’s individual needs and understanding in a case managed way. Examination of the case files show that opportunities for service users to meet with people who do not have a learning disability or who are not paid workers is severely restricted by circumstances such as risk factors and geography. The service user guide uses a pictorial format to help service users understand what they can expect the home to provide. The service is good at promoting a consistent and caring approach and ensuring service users are active participants in key decision making meetings. Service user report that they are involved in key decisions that effect them. They also confirm they can attend and participate in their review meeting and this is confirmed by the minutes of such meetings. The Trust has a range of policies and procedures that staff are expected to follow that promote these ideals. It can be seen from reading staff supervision Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 14 notes, minutes of staff meetings and the daily diary that the manager keenly promotes the importance of a consistent approach in daily routines, in managing behaviours and in meeting challenges. Attention is also given to giving attention to the importance of relaxation. Paperwork (and especially case documentation) is well presented and comprehensive. It is formatted under prescribed headings that serve to ensure consistency and wide coverage. There is a key worker system that is used effectively by service users. Case files also confirm that people can exercise certain choices regarding their health care needs and whether they follow their planned programme for the day. They also explain to staff the level of competency the person has in making choices. Paperwork also shows that meal times, bed times, bath times and week end routines vary from time to time and are different for different people. On this inspection service users indicated that they were involved in the;- choosing of clothes when shopping, meal preferences, décor and furnishings of the rooms they use and where to holiday. Any ‘house rules’ are typically based on common sense principles usually to ensure the health and safety and the well being of others. The main rules restrict smoking and alcohol consumption and access to some foods for health and safety reasons. It appears restrictions on managing medication and money, providing (or not) door locks on bedroom doors and certain restrictions on going out un-escorted which form part of most peoples care plan. Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, and 20. This is a service that excels at supporting service users to access health care services. It is good at providing personal care in a respectful and dignified way. Support staff manage medication responsibly and safely. Health needs are recorded with clarity. EVIDENCE: There are numerous policies in place that promote the service users right to dignity, privacy and respect. Examination of staff supervision records, induction check lists and staff meeting notes all confirm these area are periodically discussed and that learning points are noted. Each service user has their own room and the bathroom and toilets have locks that help ensure privacy. The whole of the service is well maintained and clean throughout with lots of personal touches that further enhance respect for the person. Examination of the care plans and other case documentation shows excellent attention is given to each to person’s individual needs. Service users report that staff are caring and based on the toiletries on view in each bedroom/bathroom it is apparent that service users are being supported to promote a positive image of themselves, as well as reflect their personality in what they wear and look like. This shows staff attend to small details as well as the bigger picture. Case records also show each service user is supported to access any specialist care and support they need, including specialist health care. Use of the “OK Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 16 Health Assessment” format for each service user ensures that their health care needs and general well being are clearly documented and comprehensive. The manager report excellent relationships between the service and the local GP surgery. Case files record the views of health care professionals as to any challenges, diagnosis or response to treatment. Medication records are well maintained and kept secure. No current service user manages their own medication. The reasons why they do not are appropriate to their circumstances as detailed in their care plan or assessment of their need. Records show all staff receive training in administering medication and that they are supervised as to their competency before they are allowed to give out drugs to service users. Staff report that typically two staff administer the medication; one to act as a check on the lead person to make sure mistakes are not made. Medication is kept secure in a cabinet. A check on the system of recording drug administration was satisfactory. Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 17 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 Complaints are taken seriously by the manager of the home and by the Trust. Those who work in the home appear to understand the importance of keeping service users safe and reporting any concerns they may have. Staff actively listen to service users views. Records show there is a low level of incidents and accidents but the numbering of incident reports appears muddled. EVIDENCE: The Trust has a detailed complaints policy, which is outlined in the service user guide and includes the option for service users to use comment cards to report any concern. There were no complaints recorded in the register of complaints for the previous 12 months. The homes policy on dealing with allegations of abuse is based on government guidance as outlined in the document, ‘No Secrets’. The manager appears to be well aware of her duty to report any concerns about any possible abuse occurring. There has been 3 referrals under the local protocols for protecting vulnerable adults in the previous 12 months. These were a result of incidents allegedly occurring at a day centre used by the service users. All these concerns appear to have been properly investigated. Staff records show that staff receive awareness raising training on abuse. The Commission are notified of any allegations of abuse and any notifications required by regulation. It was noted that some carbonised copies of incident reports did not have the same corresponding number as the top (master) copy. The manager confirmed that staff are provided with the (GSCC) General Social Care Council’s code of conduct, which staff are expected to follow. Procedures for administering monies held on behalf of service users were checked. These appeared to be in good order and regularly checked by the manager and periodically audited by the Trust. Monies held reconciled with the account balance. Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 18 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) 24 and 30 The accommodation is generally of a good overall standard. It reflects principles of ordinary living and provides comfort, privacy and general safety. Attention to certain aspects of fire safety needs to be more robust. There is evidence of continual improvements and upgrading of furniture, fabrics and décor. Rooms are compact but well proportioned. The home is not suitable for people who use wheelchairs indoors. The home appeared clean and hygienic throughout. EVIDENCE: All rooms were seen on the day of the inspection. They appeared clean, tidy and were pleasantly furnished to a good standard. Service users report that they like their rooms, all of which have been individually personalised. Rooms provide all the facilities listed in the standard (excluding telephone points), except where service users have stated they do not want such items. The home is situated within easy access of a small town. Records show the fire safety officer last visited the home in 1999. Staff are trained in fire safety and know what to do should the fire alarm sound. A service user told the inspector what they must do if the fire alarm sounds. Records also show that the fire detection system is regularly serviced and maintained. There is a recently updated fire safety risk assessment in place. Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 19 Case documentation informs staff which service users may need extra support when the fire alarms sounds. There is evidence to show that any snagging or remedial repairs are attended to on an, ‘as needed’ basis. In recent months some furniture has been replaced. An order to redecorate certain rooms has been placed with a contractor and the manager reports that there is no problem in getting things repaired if they break down. The home provides a small laundry that is separate from the kitchen. The kitchen appeared well ordered, clean and tidy. It is domestic in character. There are policies in place that raise awareness about the prevention of cross infection, including assessment of risk. Examination of staff meeting minutes show that matters relating to hygiene and controlling infection are periodically discussed. Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.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) 31, 33, 35 and 36 The staffing situation at this home is much improved since the last inspection. EVIDENCE: Service users speak favourably about the staff who work at the home. No service user made any adverse comments about the staff. All service users singled out named staff for compliments. Service users showed understanding of the key worker system and how to use it. Support staff appear to know the chain of command and each other’s roles and responsibilities. The Trust provides staff with job descriptions and other relevant guidance, which helps them get clarity of each other’s roles. All staff spoken to appeared well aware of the main aims and objectives of the service. Volunteers are not being used in this service. The staff team reflect a good balance between age and experience and reflect the culture and gender of the people living at the home. All staff were over 21 years. Since the last inspection there has been a ‘team away day’ that staff described as a success and worthwhile. It was said that as a result the staff are working better as a team and that certain past staffing difficulties have diminished. The home has a new and experienced deputy manager who appears to be making a positive impact. The home was not fully staffed and had 2.7 full time equivalent support staff vacancies. It was therefore reliant on using agency or Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 21 bank staff to provide sufficient cover. There are various staff communication systems in place, which appear well used and effective. This includes use of a communication diary, handover meetings between shift changes, periodic staff meetings and ‘one to one’ supervision meetings. Records show, and staff confirm, that in the past 6 months they have been getting regular ‘one to one’ supervision meetings. The diary shows that the deputy is scheduled to attend a couse on the supervision of staff. The manager reports that since the last inspection she has set goals with target dates as a way of better engaging staff in the process. The training of staff is taken seriously and the Trust has its own dedicated training department. Staff continue to praise the Trust for the amount of training it provides. The home is already reaching the standard of 50 staff with a National Vocational Qualification level 2 by the end of 2005 and is well placed to achieve more than 50 with level 3 in the same timescale. There is a detailed annual training plan for the service. It shows that all mandatory training for established staff is up to date. Further fire safety training is scheduled for October 2005. Behavioural management training is scheduled for Sept 05. Newly appointed staff undertake a systematic induction which broadly follows the principles laid down by the relevant learning skills council. Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.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, 40 and 42 This is a much improved home where service users are benefiting from the care and attention they receive. Good standards of health and safety are integrated into the service and service users are kept safe. EVIDENCE: A manager that strives for better standards of care is managing the home and is deemed a fit person to manage the home. Currently the manager meets the relevant standards for qualification and experience for such a position. It is evident from discussion with the home manager and her supervisor that the manager is improving the home; a view shared by the inspector. The evidence for this includes updating some key procedures, improved supervision of staff, improved staff morale and a willingness to engage with an outside facilitator to examine certain staffing issues. All relevant health and safety policies were found in place some of which have been recently updated, i.e. the medication policy and the health and safety policy were updated in June 05. The fire risk assessment was also updated in Nov 04. Discussions with staff and the manager indicate that they take safety Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 23 seriously and the reporting mechanisms are well considered well established and effective. There is a low level of recorded accidents and incident occurring. Case documentation shows evidence of detailed risk assessments in place including those that are personalised to each service user. There is a good understanding of what to do if a service users reports being harmed or abused. The home is kept tidy and clean and service users are helped to understand the importance of fire drills, good hygiene and personal safety. The absence of any visit by the local fire safety since 1999 is considered too distant to be relied upon. Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.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 x 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 2 3 x 3 3 x Standard No 31 32 33 34 35 36 Score 3 x 3 x 4 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wilcot Road (92) Score 4 4 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x 3 x 2 x DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA26 Regulation 23(2)(b)( d) Requirement The bedroom that has a ceiling showing the effects of water penetration must be made good by redecoration. (This requirement was made at the following inspection with a deadline of 29/05/05. However a survey has suggested the work should not be carried out until the plaster has fully dried out so a new timescale has been set for 12/10/05) The Trust must inform the fire safety inspecting officer of the fact that no fire safety inspection of the home has taken place since 1999. Timescale for action 12/10/05 2. YA42 23(4) 12/08/05 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 YA12 YA23 Good Practice Recommendations Consideration should be given as to how service users might be able to receive payment for any work they do outside the home. When recording incidents and/or accidents care should be Version 1.30 Page 26 Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc taken to ensure the serial number for the master copy is the same as the carbon copy(s). Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.doc Version 1.30 Page 27 Commission for Social Care Inspection Suite C, Avonbridge House BAth Road Chippenham Wiltshire SN15 2BB 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 Wilcot Road (92) DD51_D01_S28656_92WILCOTROAD_V233237_140705_STAGE4.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. 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!