Inspection on 11/05/06 for Addington Close (12)

This inspection was carried out on 11th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Addington Close (12) 07/05/09

Addington Close (12) 10/05/07

Addington Close (12) 05/12/05

Addington Close (12) 11/07/05

Addington Close (12) 22/11/04

Addington Close (12) 21/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Addington Close (12) 12 Addington Close Devizes Wiltshire SN10 5BE Lead Inspector Malcolm Kippax Unannounced Inspection 11th May 2006 10:35 Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 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 Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 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. Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Addington Close (12) Address 12 Addington Close Devizes Wiltshire SN10 5BE 01380 720001 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) Ordinary Life Project Association Mrs Helen Patricia Morgan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 3 service users with learning disabilities at any one time. Date of last inspection 5th December 2005 Brief Description of the Service: 12 Addington Close is one of a number of homes that are run by the Ordinary Life Project Association (OLPA). 12 Addington Close is a bungalow in a residential area of Devizes. The home fits in well with the neighbouring properties. The accommodation is domestic in style and consists of a living room, a dining room, a kitchen and three single bedrooms. Service users receive support from a manager and small team of permanent staff. Agency carers and relief staff also regularly work in the home. The current fees are in the range of £860.62 - £986.35 per week. Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included two visits to the home. One, which was unannounced, took place on 11 May 2006 (between 10.35 am and 4.35 pm) and a second visit, which took place on 15 May 2006 at 9.30 am. The three service users, staff members and the home’s manager were met with during the visits. Staff recruitment records were seen on 16 May 2006 at the OLPA office. Other information and feedback about the home has been received and taken into account as part of this inspection: • • • • Each of the service users’ close relatives has completed a ‘comment card’ about the home. Comments have been received from two of the service users’ care managers. The manager has completed a pre-inspection questionnaire about the running of the home. Reports and notifications received by the Commission from the home since the last inspection. The judgements contained in this report have been made from evidence gathered during the inspection, including the visits to the home. What the service does well: What has improved since the last inspection? Developments since the last inspection have mainly been in the area of personal support. There has been good contact with other professionals, which has been particularly important because of a change in one service user’s Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 6 health needs. The manager and staff team are working hard to ensure that this service user receives the care and individual support that is needed. What they could do better: 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. Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 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 Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 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 the following standard(s): 2 Standard 2 did not apply at this time. There were no vacancies and the three service users have lived together for a number of years. EVIDENCE: Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visits to the home. Staff members have good information about the service users’ individual needs and personal goals. Service users are listened to by staff and are encouraged to take an active role in the home. Service users benefit from the approach of the manager and staff team to independence and risk taking, however the benefits are reduced because parts of the environment have not been suitably adapted. EVIDENCE: Each service user had a ‘Shared Action Plan’ that included details of their personal goals and how these would be achieved. The plans had been written during the last year. It was evident from conversation with the service users that the goals reflected their interests and aspirations. The goals were individual in nature, covering such things as finding paid employment, going to a pantomime and making changes to diet. Progress with achieving the goals was being recorded by staff as part of a three-monthly review. Some boxes Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 10 needed to be completed on the Shared Action Plan records to confirm the completion of the goals. In addition to the Shared Action Plans, each service user’s personal file also included a range of assessments and guidance for staff about personal support and preferred routines. Service users were meeting together at ‘tenants’ meetings. The minutes showed that service users have ideas about what they want to do and make decisions about matters affecting them. For example, at a meeting in January 2006, the service users had discussed the level of heating in their own rooms. Different views were expressed about this and it was recorded that this would be followed up by the manager, with a view to the fitting of individual thermostatic radiator controls. Service users said that the meetings were a useful time for discussing things. One service user was able to go out independently and does several activities without the direct support of staff. Risk assessments had been undertaken, including an assessment of the risk to a service user’s independence, if not able to leave the home unaccompanied or unsupported. Guidelines about this had been produced for staff. It is good practice to balance safety and a service user’s rights in this way, as part of a risk assessment process. Although accompanied when outside the home, this service user was able to spend time without direct staff support while attending a college course. It was reported at the last inspection that another service user liked to be as independent as possible, but was restricted by the way in which the house could be accessed. See comment made under standards 26 and 42 of this report. Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 from evidence gathered before and during the visits to the home. Service users have different lifestyles, which reflect their interests and individual preferences. Service users make use of facilities in the local community, although changes in need are having an impact on what they are able to do. Service users have relationships that are important to them and their rights are respected by staff. They are consulted about the menus and what they want to do. EVIDENCE: One service user was attending a resource centre during the week and making this journey independently. The service user said that an appointment had been made with a job coach, as he wanted to have some paid employment. This service user was also attending some clubs during the week. Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 12 The other service users required more support and normally had a mix of home-based and community activities during the week. At the time of the unannounced visit, two service users were at home. One of the service users had a health condition, which meant a change to their normal routine and weekly activities. The other service user was doing domestic jobs and went out shopping with a staff member. The service user said that on other days he went to college for a computer course and attended a day centre twice a week. Staff members expressed concerns about the impact that a change in one service user’s health needs was having on the time they had to support other service users with their normal activities. The service users’ personal files included a ‘Regular Weekly Activities’ form, which gave information about daily routines. A number of the service users’ personal goals concerned new activities. Three of the service users’ relatives completed comment cards, in which they confirm their satisfaction with the visiting arrangements and communication with the home. The service users’ personal records showed that although family members were some distance away they received good support with correspondence and with keeping in touch. During the visit, one service user spoke on the telephone to their parent and arranged to have an overnight stay with them. Service users had a ‘Family Contact’ form on their personal files. Service users had keys to their rooms and said that they like to lock their rooms when they go out. The relationships between service users, staff and manager were observed to be friendly and respectful. Service users appeared to see the staff and manager as people they could be close to and talk to about their feelings. During the unannounced visit, one service user decided what to have for lunch and had been able to choose things he liked when shopping at the supermarket. Some of the main meals were being taken together and a record kept of what had been eaten. One service user had a personal goal that concerned healthy eating; some written guidelines had been produced about diet and different foods. One service user was receiving particular attention from the staff team with their nutritional needs and eating. Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 from evidence gathered before, during and after the visits to the home. Service users benefit from the support that they receive from the manager and staff. Changes in health needs are being followed up, which ensures that service users have access to specialist services. Service users receive the support that they need with their medication. EVIDENCE: Each service user had an individual plan for personal care and support that had been written in October / November 2005. Some amendments had been made to the plans in 2006 and six-monthly reviews were due to take place. Staff members had signed the plans to confirm they had read them. Service users had their own rooms where personal care could take place in private. The rooms were close to a bathroom and toilet. The service users’ personal files contained health records with details of contact with GPs and other healthcare professionals. The records showed that ‘complaints’ by service users were being followed up through GP appointments and that staff were monitoring the service users’ on-going health needs. One Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 14 service user went to their GP independently during the visit on 11 May. Several recent appointments with GPs, dentists and others had been reported, although one service user’s records showed that a dental check up had taken place over a year ago. The manager was confident that a more recent visit been made and confirmed that this would be followed up. Each service user said that they were happy with the support they received. The service users’ relatives and care managers also reported that they are satisfied with the standard of care. The staff meeting minutes showed that the service users’ health and well-being were regularly discussed. Changes in one service user’s health needs were being responded to at the time of the visits. The manager and staff were very aware of their duty of care to this person and during the visits they spoke positively about how the service user could best be supported. Several meetings with different outside professionals had taken place and visits were being made by the community nurse. These matters were well recorded in the service user’s personal file. Assessments of the service user’s condition were on-going at the time of the inspection. The manager said that an occupational therapist had provided guidance for staff in the use of a hoist with this service user and a physiotherapist was due to visit on the afternoon of 15 May to assess transfers not involving the hoist. Staff members administer the service users’ medication and there are suitable storage arrangements in place. The ‘patient information’ leaflets were available together with other guidance for staff about the service users’ prescribed drugs. Service users had signed consent forms confirming their agreement for staff to administer their medication. The records of administration and stock were up to date. One service user was being administered eardrops under the instructions of the community nurse. It was agreed with the manager that it would be better to record this on the medication administration cards, rather than in the service user’s personal diary. During the visits there was discussion with staff about one service user’s ability to take some responsibility for their own medication. This may be something that the service user wishes and is able to do. Staff members who administer medication receive training in the medication procedures an ‘in-house’ basis from an OLPA Service Co-ordinator. Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 from evidence gathered before and during the visits to the home. Service users are encouraged to raise concerns and they have the information they need about making a complaint. There is staff awareness of abuse, which helps to protect service users. EVIDENCE: OLPA has produced a complaints procedure and copies of this have been given to service users to keep in their rooms. The two service users who were asked both mentioned people who they could talk to if they were not happy with something. In their comment cards, relatives confirmed that they are aware of the home’s complaints procedures. Service users have been reminded at the house meetings of how to make a complaint and whom they can contact. The minutes showed that the service users’ views are listened to, with people identified as being responsible for following up any concerns that have been raised. A file for the recording of compliments and complaints was displayed by the front door. No complaints had been reported since 2003. More recently, the staff team had been complimented on the support they give to a service user with their personal appearance. Abuse awareness is included in the OLPA training programme for support workers. The subject is covered in a short statement in the home’s policy and procedure file, which makes reference to ‘No Secrets’ and to a guidance Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 16 document on the protection of vulnerable adults from abuse in Swindon & Wiltshire. Staff confirmed the training that they had received and that they had been given a copy of the ‘No Secrets’ booklet, which gives guidance about abuse and what to do if abuse is suspected. Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before and during the visits to the home. 12 Addington Close provides service users with homely and domestic type accommodation. The service users’ independence is reduced because some environmental adaptations have not been made. The accommodation is kept clean and tidy. EVIDENCE: The home is situated in a quiet cul-de-sac and the property is in keeping with the local area. The accommodation looked homely and was comfortably furnished. There was a good-sized rear garden with a patio area and barbeque. One service user goes out independently to several places that are within walking distance of the home. Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 18 During the last year the Commission has received information about some maintenance work and environmental adaptations that have been recommended by an occupational therapist (O.T.). The need for this work was identified in 2002 after the home’s manager had requested an O.T. referral. The work included carrying out repairs to the driveway so that one service user in particular can use it without the increased risk of hurting herself. The driveway also had an irregular surface that is prone to flooding. The O.T. has also said that, as a consequence of the increasing frailty of two service users, it is necessary to improve access through the front and back doors. This involves changing the door thresholds so that they are less of an obstacle to service users. There was a requirement at the last inspection for the Commission to be informed of a date for completion of the environmental adaptations and work recommended by the O.T. OLPA have reported on the action that is being taken but a date for the completion of the work has not been confirmed. During the visit, the manager said that estimates were being obtained for the work on the driveway and consideration was being given to the fitting of a ramp up to the front door as a temporary measure to improve access. It was reported at the last inspection that one service user would like to have a shower in the bathroom. A shower had been bought, but not fitted. The manager said that this work was now planned to take place. There was a homely lounge and a separate dining area. The facilities for staff were not ideal as staff had to sleep in the lounge once service users had gone to bed. The dining area was also being used as an office base although the manager had recently made changes, which meant that the dining table no longer needed to be used as a desk for administrative work. The home looked clean and tidy. An environmental health officer last visited the home in November 2005. There were no recommendations or requirements made in respect of the kitchen. There was discussion at the last inspection about plans for the redecoration / refurbishment of the lounge and the kitchen. The manager has said that there was no planned programme of refurbishment. This was recommended as being a way of ensuring that larger works involving capital expenditure are completed in a timely manner. The manager had included some relevant matters in her business plan for the home. Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visits to the home. Service users are supported by staff members who they like and who know them well. They would benefit from a more flexible and pro-active approach to determining staffing levels and how staff are deployed. This would help ensure that changes in need are appropriately responded to with additional staffing where needed. New staff members get to know OLPA’s procedures, but do not receive the recommended induction for working with people in a learning disability service. There is a well-established programme of in-house training. Further developments are taking place, which will be of benefit to service users by providing staff with some new training opportunities that are relevant to the service users’ needs. Service users are protected by the organisation’s recruitment practices. EVIDENCE: In addition to the manager there was a permanent staff team of four support workers. One support worker had achieved NVQ level at 3 and another had achieved level 2. The manager reported that two others would be starting Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 20 NVQ level 2 shortly. The staff team includes experienced support workers who have worked in the home for several years. One staff member had been appointed during the last year. Recruitment was discussed with the OLPA personnel officer and service coordinators at the OLPA office. The main employment records are held centrally, with copies of documentation also kept in the home. It was agreed that future arrangements could include inspection of the records at the office and the need to keep records in the home would be removed. However a recruitment checklist would need to be available for inspection in the home. The employment records for a number of OLPA support staff were looked at. Each staff member had an individual file. There was some inconsistency in the files’ contents and in the completion of an employee information form, which is used as a checklist during recruitment. It is recommended that this form is updated, as a number of new recruitment checks, for example POVA / C.R.B., have been introduced since the form was produced. The most recently appointed support worker said that she had attended an Induction day at the OLPA office and completed an in-house induction. Learning Disability Award Framework accredited training is not available; new staff members are therefore not receiving an induction that meets the expected standard and is consistent with national policy for learning disability services. Following induction, the staff member had attended training events as part of OLPA’s in-house programme. This had included first aid, manual handling, food safety, medication, risk assessment, health & safety and abuse awareness. Each staff member had an individual training portfolio. Staff members had received statutory training, although other areas of training, such as shared action planning, had not been completed. Some new subjects have been included in the OLPA in-house training programme for the year ahead. This should be beneficial in developing the staff team’s knowledge of learning disability and care related subjects. Support workers and the manager spoke about a change in one service user’s needs, which meant that this service user required a higher level of personal support. Staff said that this was putting pressure on their time and that the need to give greater attention to one service user was having an impact on their support for the other two. This had not yet been resolved with the provision of additional staff hours. The manager said some additional hours could be used although there were concerns about whether this could be provided by staff who knew the service users. Agency carers were being used to cover for staff leave. This necessitated a lengthy handover when the agency carer started work, particularly in relation to one service user’s needs. It was recommended at the last inspection that an appropriate system is used Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 21 for calculating staffing levels based on the needs and personal goals of the service users. This has not been applied. During the visits, the manager and staff spoke respectfully about the service users, who said that they got on well with the staff team. Relationships were observed to be friendly and easy-going. In the comment cards, the relatives confirmed their satisfaction with how staff approach their work. Staff members were described as very friendly, helpful and committed. Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, and 42 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before and during the visits to the home. Service users enjoy an open and informal atmosphere. The management approach within the home is well focused on the service users’ needs and welfare. However the benefits are reduced by a lack of improvement and attention to the physical environment. There is a lack of quality assurance at an organisational level although the manager is developing this within the home. The driveway and door thresholds need to receive attention to ensure that the service users’ health & safety is promoted and protected. EVIDENCE: The home’s manager has a specialist nurse background and is suitably qualified for her role. The manager has completed the Registered Managers Award and was undertaking NVQ level 4 in Care. Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 23 The relationships between service users, manager and staff members were seen to be friendly and positive. The manager and staff members talked about service users in a respectful manner, and were aware of the need for confidentiality and privacy. Relatives commented positively about their experience of 12 Addington Close, with one person describing it as a very professionally run home. OLPA has achieved the ‘Investors in People’ award. An OLPA service coordinator was visiting the home regularly and was involved in the recruitment of new staff. The manager met with prospective staff members in the home but did not participate in the formal interviews. There was no evidence of organisational audit or system for the monitoring of standards. The OLPA policy for quality assurance listed out a range of devices by which feedback could be obtained from interested parties. Service users were able to pass on their views during the ‘tenants’ meetings in the home and through shared action planning. The policy for quality assurance did not refer to the production of an annual development or improvement type plan. The manager had produced a business plan for 2005 – 2006, which included some objectives for the home, in areas such as staff training and the environment. This is a positive initiative although a more pro-active approach is needed at an organisation level to quality assurance and annual development. The lack of attention and response to recommendations made by the occupational therapist was evidence that improvements are not being appropriately carried out in a timely manner. The manager has undertaken risk assessments in relation to the hazards involving the driveway and the door thresholds. Information about health & safety, including the maintenance and servicing of equipment was received from the home in a pre-inspection questionnaire. A check was made of the home’s fire log book, which showed that tests of the smoke alarms were up to date and the fire risk assessment was last reviewed in August 2005. A ‘Kitchen’ file included a record of various domestic checks and safety monitoring that take place on a regular basis. Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 24 Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 25 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 N/A 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 3 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 2 x Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA42 Regulation 23(2) Requirement The registered person must ensure that risk assessments in respect of the driveway and door thresholds are kept under review and that action is taken to implement appropriate safety measures. Timescale for action 12/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA20 YA20 Good Practice Recommendations That the ability and wish of service users to take responsibility for their own medication is assessed. That, in addition to the ‘in-house’ training, staff members also receive training in medication from a specialist outside the home. (This recommendation is outstanding from the previous inspection). That a programme of refurbishment is produced for the home. (This recommendation is outstanding from the previous inspection). DS0000028256.V289073.R01.S.doc Version 5.1 Page 27 3. YA23 Addington Close (12) 4. YA33 That an appropriate system is used for calculating staffing levels based on the needs and personal goals of the service users. (This recommendation is outstanding from the previous inspection). That LDAF accredited training is provided for new members of staff. (This recommendation is outstanding from the previous inspection). That the employment checklist is updated to include all aspects of the recruitment process. That the registered manager is involved in the formal interviews for new members of staff. That the policy on quality assurance is amended to include the arrangements made for annual development and for the production of an improvement plan. 5. YA35 6. 7. 8. YA34 YA37 YA39 Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham 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 Addington Close (12) DS0000028256.V289073.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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