Inspection on 14/11/06 for Amberleigh

This inspection was carried out on 14th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Amberleigh 18/09/08

Amberleigh 10/01/06

Amberleigh 05/07/05

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 Amberleigh 24 Isaacs Close Street Somerset BA16 0LS Lead Inspector Pippa Greed Unannounced Inspection 14th November 2006 10.00 Amberleigh DS0000061823.V316278.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 Amberleigh DS0000061823.V316278.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. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amberleigh Address 24 Isaacs Close Street Somerset BA16 0LS 01458 840865 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) Somerset County Council (LD Services) Mrs Pauline McLean Molland Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users may be admitted who have concurrent sensory and or physical impairment Service users are admitted for a maximum of three months Date of last inspection Brief Description of the Service: Amberleigh is a service for residential short breaks which caters for service users in the Younger Adult Category. Two of the six beds are used for emergency or assessment purposes. All the rooms are for single occupancy. There are a number of communal areas including sitting and dining space. In addition there is a conservatory, which is used for quiet time. The service has a very small garden area to the rear this is accessible to the people who live at the service. There are an adequate number of adapted bathrooms. The current scale of charges is between £50.00 and £94.00 per week. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key Inspection was conducted over one day (6.5hrs) by CSCI Regulation Inspector Pippa Greed. On the morning of the inspection two care support workers, one care support assistant and one manager were on duty and during the afternoon there were one care support worker, two care support assistants. The registered manager Mrs. Molland was available to assist the inspector during the unannounced visit. On the day of the inspection one service user was at home. The atmosphere was relaxed and informal. Staff were seen to work professionally and demonstrated good rapport with the service users. The inspector viewed all communal areas and also some service users rooms. The inspector met with one service user and three staff members. A selection of records was examined. These included three service users care plan and four staff recruitment files. CSCI sent out feedback cards for six service users, and three social workers. The manager sent out six relative cards on behalf of CSCI. Three service users surveys have been received, all of which were completed with advocated support. One service user commented ‘Amberleigh is a nice place’. Another service user wrote ‘Sometimes when I want to go to town, there are not enough staff’. One parent commented their behalf - ‘They are all wonderful. Amberleigh is a wonderful place’. One social worker comment card has been received and this reflected positively on the service provided. The inspector would like to thank the service user, staff and manager for their time and hospitality shown to the inspector during her visit. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: The service provides a valuable service to the local community providing short breaks for service users and their carers. The staff team appear dedicated, supportive of one another and committed to the service they provide. The service was clean and tidy on the day of inspection. People who access the service who were able to give an opinion all gave positive comments about the service they received. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Amberleigh DS0000061823.V316278.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 Amberleigh DS0000061823.V316278.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides a statement of purpose, and service user guide that clearly sets out the objectives and philosophy of the service. Prospective service users are given the opportunity to spend time in the home prior to admission. Each service user is provided with a clear statement of terms and conditions that sets out the terms and conditions of residency. Service users are provided with respite care in order to maximise their independence and prepare them for their return home. EVIDENCE: Each service user is provided with a written and pictorial statement of terms and condition of residency. There is a trial period of at least half a day followed by an overnight stay. Length of visit will be ‘tailored’ and agreed to allow prospective service user the opportunity to find out if the home meets their needs. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 9 The service user is also provided with a Statement of Purpose and a Service User’s Guide. The Service User’s Guide is provided in Somerset Total Communication which uses pictorial symbols used within the Somerset County Council network services. The symbols are easy to understand and the guide explains what the prospective service user can expect from Amberleigh. This enables the service user to make an informed choice. The care plan sampled provided evidence of pre-admission assessments for recent admissions. The home also has a clear and concise flow chart detailing appropriate steps to take when conducting short-term emergency admission procedure. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a detailed care plan for each service user. Service users are encouraged to exercise choice and participate in all aspects of life within the home. Service users are supported in taking risks. Records relating to service users are stored securely and appropriately maintained. EVIDENCE: Care plans are maintained for each service user. Three care plans were examined during this inspection. Those care plans seen were detailed and provided information regarding service users needs, daily routines and preferences. Care plans had been regularly reviewed and updated as required. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 11 Service users are encouraged to exercise choice, wherever possible. Staff have a good understanding of service users’ needs and respond to choices that are expressed through verbal and non-verbal communication. Communication systems are widely used through out the service. Pictures and symbols are used to inform service users of such things as the menu for the day, where things are kept or activities that will be available on that day. Risk assessments had been completed for each service user. These are categorised and colour coded in relation to level of risk. This ensures that the information provided is clear and concise. Care plans included details of strategies to be used to manage challenging behaviour, where necessary. The care plans seen included specific manual handling risk assessment for each service user, which is good practice. There is also a manual handling risk assessment file kept for residing service users in the bathroom. These files provide staff manual handling guidance and instruction for each service user. This is stored appropriately and locked away when the service user is not in residence. The care plans are stored in a secure manner. The care plans evidenced that the service users are supported in making decisions and exercising choice over their lives. Daily Living Skills objectives set by the home and service user provide structured goals. These were signed where possible. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home offers service users opportunities to engage with peers, access appropriate leisure activities, and exercise choice. Service users rights and responsibilities are respected. EVIDENCE: Service users are provided with a range of activities that are appropriate to their individual needs, and are supported in accessing the local community. On the day of the inspection, one service user was at home and three service users were attending The Beckery Day Centre. The level of staffing at the home provides service users with the opportunity to participate in a range of activities. These include: day centre access, music & relaxation, gardening, ‘flexicise’, accessing the community, and social club at the Tor Leisure. On the day of the inspection, a service user was participating in a music and tactile exploration session. There is a sensory room in the Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 13 home, which provides soft mats, beanbags, light projector, tactile toys, and water bubble display. In-house activity resources are provided and much improved. The home has use of a minibus to access local facilities. The bathroom also has underwater spa lights for service user’s enjoyment. The care plan included an ‘interests’ checklist, which is used when a new service user resides at the service. This helps establish their personal interest and leisure preferences and contribute to care planning if needed. The home provides support with equality and diversity needs such as appropriate skin care or dietary requirement for those in ethic minority. The manager is currently putting together an activity reference book which includes photographs and total communication symbols listing a range of activity available. The home has been reviewing current practice and has recently introduced staff passport. Staff have a communication passport, which service user can look at, and get to know the staff member. This is a helpful tool in developing rapport. This is to be commended. Staff supports service users in maintaining contact with friends and family members. Visitors are welcomed at the home. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are provided with appropriate assistance to meet their personal care needs. The home supports service users in accessing healthcare services. The home has a medication policy, which provide staff with clear guidance. Medication records are managed safely. EVIDENCE: All service user rooms are single occupancy and have sink en suite facilities. Care plans provide details of the level and type of assistance each service user requires to meet their personal care needs. Service users visit the GP with staff support if and when required. Service users are also supported to attend any pre-arranged healthcare visits. All visits to health and medical services are well documented in the service user plan. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 15 The Manager had ensured that staff receive training in relation to service users’ specific health and personal care needs. The manager has arranged comprehensive health and medical training for the staff such as peg feeding, bolus feeding, epilepsy, mental health, dementia and medication. All medications were stored securely. The medication records were examined. Each service user has a medication file which is detailed. This includes photograph of the service user, and written records of phone contact with GP. A record had been maintained in relation to all medications entering and leaving the home. Two staff signatures further support this record. Medication stored were sampled and checked. These were checked daily by staff and fell within the correct date period. The service provides lockable cabinets in each room, should the service user wish to self-medicate. The care plan includes a section, which outlines service users end of life wishes where applicable. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place for the protection of vulnerable adults from abuse. It is recommended that staff receive POVA training as good practice. The home has a complaints procedure and policy relating to the Protection of Vulnerable Adults. However, the Somerset County Council ‘Whistleblowing’ leaflet does not include the Commission’s contact detail. EVIDENCE: The home’s complaints procedure were included in all service users’ care plans. This is provided in an accessible format including Total Communication symbols. The information on how to complain is also available in pictorial form, or a video is available. This is good practice. Three service users surveys stated that they knew who to speak to if they were not happy. One parent confirmed in the service user’s survey that they felt comfortable advocating and raising issues of concern to staff and management. The home has received three complaints since the last inspection, and the manager has taken appropriate actions to address the issues raised. The home has a complaints procedure that provides guidance details however it did not include CSCI contact details. A copy of this policy is displayed in the office. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 17 The home has appropriate policies relating to the Protection of Vulnerable Adults. The home has obtained a copy of Safeguarding Vulnerable Adults in Somerset, Multi-Agency Policy. In discussion with the inspector, staff confirmed that they knew where the policies were stored. Two from three staff stated that they have not received Vulnerable Adults training. Staff recruitment files confirmed that Criminal Records Bureau (CRB) checks are in place. The inspector was not able to assess whether Protection of Vulnerable Adult (POVA1st) were implemented as the home has not recruited any new staff in the last year. New staff member working at Amberleigh have been transferred from other Somerset County Council homes, therefore were not new employee as such. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has been decorated and furnished to an adequate standard. The home has sufficient communal areas and bathrooms to meet service users’ needs. Appropriate adaptations have been provided. The home was found to have a good standard of cleanliness. EVIDENCE: The home is a purpose built unit and provides respite care. The home is adapted to a high standard to meet the range of disabilities that service users may have. A tour of the building was conducted during the inspection. All the bedrooms are for single occupancy with sink en-suite facilities. One service user’s bedroom was viewed with permission. The bedrooms viewed were found to be personalised and comfortable. Some bedrooms were equipped with overhead hoist track to provide assistance Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 19 with mobility if required. The manager has acquired several new electric beds equipped with bed rails. The new beds can be adjusted electronically to raise service user into different positions. Some of the rooms that were inspected had window restrictor in place. Room 4 and 5 (vacant rooms) had window restrictor that needed adjusting. Whilst the majority of bedrooms have built-in wardrobes, one freestanding wardrobe will require an environmental risk assessment or be made secure. Furnishing in some rooms would benefit from an upgrade. There are three toilets in this home with adequate space for wheelchair users. There is one very large shared bathroom with a bath suitable for service users with severe mobility impairment to access via an overhead hoist. The water temperature of the bath is displayed on a digital readout. There is also a shower trolley available, where adequate space is provided for its use in the bathroom. All washing and bathing facilities inspected were clean and tidy. Also, paper towels and liquid soap were available. Water temperatures records were checked and found up to date. Communal space at the home includes a large lounge and a separate dining area. The lounge is comfortable and homely. The home has a conservatory, which is used as a sensory room as well as additional communal space. The kitchen is spacious and provides good storage and cooking facilities. The kitchen units have Somerset Total Communication symbols displayed on the cupboard to inform a person of it’s content. The laundry provides good equipment for washing of clothes and machines enable programmes to heat to a degree to manage infection control measures. All chemicals are stored in a locked cupboard. The tumble drier is a domestic type, which is currently housed in the conservatory. The manager informed the inspector that she is presently submitting quotes in order to obtain an industrial condenser drier for the laundry room. Amberleigh has limited accessible outdoor space. The surrounding lawns are well maintained. Pictorial signs were evident throughout the home to signpost fire exit or toilets. The home was maintained in a clean and hygienic condition. Western Challenge currently manages the premises. A number of areas have peeling paintwork, damp patch and missing plasterwork. This reduces significantly the overall ambience of the environment. Somerset County Council are currently discussing with Western Challenge remedial works required. These works however have been outstanding for a significant period Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 20 of time and should be made urgent priority. Western Challenge has provided Somerset County Council with an anticipated schedule. The schedule does not provide specific dates to indicate when remedial work will be carried out. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are experienced and provide a good standard of care. Staffing levels are appropriate to meet service users’ needs. Training updates in Adult Protection for the staff is recommended. Staff receive appropriate support and supervision. EVIDENCE: Duty rotas are maintained. On the day of the inspection, two care support workers and one care support assistant were working during the morning. The manager works day shift to provide guidance, support and carry out administrative duties. Three staff was rostered to work during the afternoon and four waking night staff to cover all four homes. The service currently staffs two other services. It was recommended that these areas have their own staff team to reduce the effect that this has on Amberleigh. This would have enabled the management team to focus their efforts on the staffing structure within Street homes. Whilst it was evident that Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 22 staffing levels are increased depending on the needs of the people who are using the service at the time, Amberleigh continues to staff other homes as and when required. This provides consistency for the other homes but hinders the stability within Amberleigh. This recommendation remains. Somerset County Council network has provided the Manager with a training analysis to track staff training needs. This will ensure that all staff are provided with mandatory and appropriate training to undertake their role. Newly employed staff are provided with a thorough Induction programme. Staff spoken with confirmed this. Staff are provided with regular opportunities to receive training, and have attended courses such as Health and Safety, Food Hygiene, First Aid, Fire, Manual Handling, Autism, Equality & Diversity, Mental Health, and Epilepsy. It is recommended that Adult Protection training be provided for all staff. Staff recruitment files evidenced that supervision meeting are provided six weekly. Staff spoken with said they felt well supported. Eight of the fourteen staff employed have obtained the NVQ level 2 qualification in care, which exceeds the 50 recommended by National Minimum Standards. Four staff recruitment files were examined. One was found to contain the documentation required within Schedule 2 of the Care Home Regulations 2001. Three files did not contain application form or two written references. It is required that the home updates all staff personnel records to evidence information required by National Minimum Standards. The inspector was unable to assess whether Protection of Vulnerable Adults (POVA1st) would be carried out as Amberleigh has good staff retention including transferred staff from within the Somerset County Council network. Amberleigh has a dedicated staff team in sufficient numbers to meet the needs of the people who access the service. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well run. There is a relaxed and open atmosphere within the home. Staff endeavours to promote the rights and best interests of service users through person centred approach using total communication. Appropriate actions have been taken to promote the health and safety of staff and service users. EVIDENCE: Mrs Pauline Molland is the Registered Manager. Mrs Molland has many years experience of providing care to a service users who have a learning disability. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 24 Staff at the home seek service users’ views on an individual basis, taking account of behaviours, verbal and non-verbal communication. Staff spoken with confirmed that the Manager was approachable and that they would be able to raise any concerns. The home has appropriate policies and procedures in place to safeguard vulnerable service users. All records relating to service users are stored securely in accordance with the Data Protection Act 1998. Staff spoken with confirmed that the management team were supportive and open. Staff informed the inspector that they have staff meetings every one or two months. Overhead hoists, Lifting Operations, Lifting Equipment Regulation (LOLER) were checked on 8/8/06. A bedrail was checked and was fitted correctly. Fire safety records were examined. Fire equipments were tested in November 2006. Staff completed in-house fire questionnaire during July and August 2006. There are notices displayed in throughout the home in Somerset Total Communication that provide details of the actions to be taken in the event of a fire. The inspector viewed records relating to medication, water, portable appliance testing (PAT), Control of Substance Hazardous to Health (COSHH), and manual handling assessment. Health and Safety checks are maintained and up to date. The home was generally found to be well organised and well run. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 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 3 2 3 3 3 4 3 5 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 1 3 Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 YA24 Regulation 23 Requirement It is required that the management clarify with Western Challenge when the refurbishment upgrade work will take place. Also, to forward to CSCI an action plan detailing plans for refurbishment. It is required that the manager completes an environmental risk assessment to include freestanding wardrobes and unrestricted window openings. It is required that broken or damaged furnishings be replaced. It is required that the home updates all staff personnel records to evidence information required by Schedule 2, Care Homes Regulations 2001. Timescale for action 31/01/07 2. YA42 13 4(a) 18/12/06 3. YA42 13 4(a) 18/12/06 4. YA34 Schedule 2 (5) 31/01/07 Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA31 YA35 YA42 YA42 YA42 Good Practice Recommendations To implement a strategy plan which reduces the need to relocate staff to satellite services. To provide Protection of Vulnerable Adult training for the staff team. To submit Regulation 37 to CSCI when absconding procedure is activated or service user is admitted to A&E. To arrange for an external contractor to provide Legionella checks at least once a year. To arrange for a suitable condenser drier to be installed in the laundry area. Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Amberleigh DS0000061823.V316278.R01.S.doc Version 5.2 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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