CARE HOME ADULTS 18-65
Bailey Close 8 Bailey Close Haverhill Suffolk CB9 0LH Lead Inspector
Julie Small Unannounced Inspection 21st September 2005 16:10 Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 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 Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 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. Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bailey Close Address 8 Bailey Close Haverhill Suffolk CB9 0LH 01440 763290 01440 705580 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) Mrs Nemelita Seneviratne Mrs Nemelita Seneviratne Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th March 2005 Brief Description of the Service: Number 8 Bailey Close is a detached house, which is registered under the provisions of the Care Standards Act 2000 as a care home to accommodate a maximum of five people with a learning disability. The home is situated in a quiet cul-de-sac on a residential housing estate that is approximately one mile from the centre of Haverhill. There is a regular bus service within walking distance of the house. The accommodation is domestic in nature, providing five single bedrooms, three on the ground floor and two on the first floor, all with hand washing facilities. The home provides a communal lounge where residents can meet friends and relatives or watch the television. The lounge opens out to an enclosed garden laid to lawn with shrubs and a bird birth, a patio area with seating is also provided. Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place on Wednesday 21st September 2005 between the times 16.10 – 19.15. The inspector was Julie Small, who was welcomed into the home by a support worker and later by the manager of the home. Four residents are currently accommodated at Bailey Close; all residents were spoken to during the inspection. The manager and one support worker were also spoken to. A tour of the building and observation of work practice was undertaken by the inspector, staff and resident records were viewed. What the service does well:
Interaction between residents and staff at Bailey Close was observed to be excellent. There was lots of laughter and friendly interaction between residents and staff and residents with each other. The inspector was included in the fun of the home, and was made very welcome by both residents and staff. All residents were keen to tell the inspector about themselves and the care they receive at Bailey Close, which they did confidently. These conversations showed that residents are provided with choice, they are included in decisions about the home and their views are valued and listened to. All residents said that they enjoyed each others company, and all had lived at the home for several years. One resident said ‘I wouldn’t want to live anywhere else’. At the time of the inspection, two residents had returned from work to the home, another two residents had gone to the hairdressers after work. When all residents had returned to the home, three of them prepared to go out to a club. The residents take turns in preparing the evening meal; everyone in the home sits down to eat their meal together. All residents take turns in chores around the house and complete these well, the home is clean and tidy. Discussion with the manager and staff at the home showed that the residents well being is central to their work at Bailey Close. The manager and the staff have a clear knowledge about the resident’s individual needs. One resident has a specific dietary need, the resident clearly told the inspector about this and why they have the need. This shows that residents at Bailey Close are included and consulted in their health care needs. Bailey Close is comfortable and ‘homely’. Resident’s bedrooms are personalised and each room shows the individuality of the residents. There are lots of ornaments and memorabilia are in the communal living area. This shows that residents use the communal areas as their own space as well as their bedrooms. Residents stated that they do have visitors at the home and these are made welcome, they can visit in private if they wish. Staff spoken to stated that communication between staff and the manager is very good. Handover meetings occur with each change over of shift and there
Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 6 are staff meetings. Staff spoken to said that even when they are not at work staff speak to each other, which shows the commitment of the staff team to the care of the residents. The inspector observed the positive communication between staff and the manager. What has improved since the last inspection? What they could do better:
The registered manager should continue with finding an appropriate training provider to complete the NVQ level 4 in management. NVQ level 2 should be provided for more than one member of staff if Bailey Close is to achieve the target of 50 of staff to have achieved at least NVQ level 2 by 2005. Supervisions should be formalised and recorded for all members of staff and provided at least six supervisions for each member of staff in a twelve-month period. Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 Prospective residents can expect that their individual needs and aspirations are assessed and met. EVIDENCE: The four residents currently living at Bailey Close have lived there for several years, the minimum length of time being five years. No newly admitted resident’s files were available, two long-standing resident files were viewed. Both files contained needs assessments completed by the manager of the home. One file contained needs assessment completed by the purchasing authority and a written record of the resident’s history completed by a family member. Assessments included what support is required, the important people in the residents lives, risk assessments, physical and mental health care, method of communication and behaviour. Care plans are present which include the daily care that a resident needs. Each file viewed has an individual service agreement present. Interaction was viewed between staff and residents this was observed to be positive. All residents use the English language and do not have any sensory problems. The manager asked the inspector if the inspection report is in picture format to aid the understanding of the residents who do not read. Four residents spoken to all stated that they are happy at Bailey Close and that their needs are met. Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 10 Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 11 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, 8 Residents can expect that their assessed and changing needs and personal goals are reflected in their individual plan. Residents make decisions about their lives with assistance as needed and are consulted on, and participate in, all aspects of life in the home. EVIDENCE: Two resident files were viewed; these each contained an individual care plan, which clearly shows each residents individual needs. Each resident also has an individual weekly routine chart, which shows all activities, which the resident participates in throughout the week. Care plans and weekly routine charts are amended with the changing needs of a resident. Files viewed contained needs assessments completed by the manager of the home. One file contained an assessment completed by the purchasing authority and a detailed history of the resident completed by a family member. The care plans reflect the details recorded in the needs assessments. One care plan viewed, has a behaviour management programme, indicating the residents different behaviours over time and possible triggers to aggression. The manager confirmed that there are no longer issues.
Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 12 One resident’s care plan showed that they have a specific diet requirement due to a medical condition. The resident was spoken to and informed the inspector of their requirement and the reason why. The resident was well informed about their condition and methods of living with it. The resident said that they prepare their own bread and baking to meet their needs. This shows that where there may have been an issue around restrictions on choice, the home have supported the resident in taking control of this issue. Two residents stated that they have key workers at Bailey Close; one resident said that their key worker ‘is there to look after me and make sure I’m alright’. All four residents spoken to were clear on the roles of the manager and support staff, and said they can talk to the staff and the manager. The residents said that they talk about what they want and how it will be provided for them. Records viewed and residents spoken to show that residents make decisions about all aspects of their lives. It is clear that Bailey Close encourages and supports resident’s independence, views and choices. Two resident records show that the residents pay for their care through direct debit, and they collect money as they need it from the bank, and are self managing in this. There is a risk assessment in place for these residents collecting monies, and the residents are clearly informed about their personal safety. Residents spoken to and the manager confirmed that there are regular house meetings where any issues that arise may be discussed. It was observed during the inspection that all those in the home sit together and meal times and discuss plans for the evening, what they have done at work that day and any decisions that are required about the running of the home. The residents spoken to were very confident and well informed about the care they receive, their needs, what is provided in the home and any decisions made about the running of the home, which may affect their lives. Three residents stated that they have chores around the house, which are changed every two weeks; residents also take it in turns to prepare and cook the evening meal. One resident said that they shop for food at the weekends. Residents confirmed that Bailey Close is their home and that they should take responsibility for where they live. The residents spoken to appeared proud that they contributed to the day to day running of the home and the inspector congratulated them on such a good job. Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 13 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): 11, 12, 13, 14, 16, 17 Residents have opportunities for personal development and are able to take part in appropriate activities, and are part of the local community. Resident’s rights and responsibilities are recognised and respected. Residents can expect to be offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: Four residents spoken to all were assertive and confident in informing the inspector about their life, Bailey Close and the part they play in their home. Residents were well informed about their needs and how to get them met. The residents spoken to stated that they go to work and explained where in Haverhill this is. All residents had a clear role in their jobs and two of the residents showed the inspector qualifications they had obtained at work which were National Vocational Qualifications in food and hygiene. These were in frames and on their bedroom walls. There were several more certificates on the two residents walls, which they confirmed they had achieved in a previous college course, these included assertiveness, and personal and social competence. One service user showed the inspector a collection of sports medals and trophies they had been awarded through sports activities.
Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 14 Two residents stated that they go bowling and play snooker at a local snooker and bowling venue. One resident said that they travel on the bus every other weekend to a neighbouring town to meet family members. One resident had a large ‘loom’ in their bedroom with the beginning of a rug on it. The resident said that they make rugs and showed two rugs in Bailey Close that they had made. The resident said that the one they are currently working on is for a neighbour of the home. All four residents spoken to said that they attend several evening clubs in the local community. One resident said that they used to go to one club, but stopped going, as they didn’t like it. The resident said that staff asked why but didn’t make them go. One resident said that the group could go out together if they want, they said ‘sometimes I like to go to my room and listen to records and no one bothers me’. Resident’s bedrooms were viewed. Each resident took responsibility for showing the inspector their own room; one resident had a play station game and records in their room. One resident had word searches, videos and jigsaws in their room. Residents pointed out what they enjoyed and what they have bought to entertain themselves when at home. One resident had their own room key and opened their locked door to show the inspector their room. One resident spoken to said they had their own key but had not locked their door. Residents spoken to said that staff always knock their bedroom doors before entering. Four residents spoken to told of their responsibility in doing chores in the home, which are rotated two weekly, they also take it in turns to cook the evening meal. All residents said that they clean their own bedrooms. Records viewed showed residents daily routine charts, which show what activities a resident, chooses to do throughout the week. At the time of the inspection two residents had attended a hairdressers appointment, staff had driven them there after work and the residents telephone to be ‘picked up’ when they had finished. Three residents were observed to be preparing to attend a local club; they left for the club by taxi. The manager confirmed that the club’s staff meets the residents at the club when they arrive. Interaction between residents and staff was observed to be very positive. The atmosphere was very ‘light hearted’ and there was lots of laughter. At all times the staff and manager involved the residents in their discussions, this did not appear to be an out of the ordinary practice. Residents and staff were very comfortable in each other’s company. One resident said that their family visit often and they can come when they like and are made welcome. The resident said they sometimes arrange so they can have the lounge or the dining room to visit in private if the other residents are in agreement.
Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 15 At the time of the inspection it was teatime, one resident took responsibility for cooking the evening meal, all residents were asked what they wanted and agreed on the same thing. Staff confirmed that at mealtimes everyone sits around the table, eats and chats. This was observed during the inspection, though some had their meals at different times due to the trip to the hairdressers and the preparation to go out to club. One resident record showed that the resident has a specific dietary requirement due to an illness; the records showed what the resident can and can’t eat. The resident was spoken to and was very well informed about their requirements and their illness, they told the inspector that they do their own baking with specific ingredients. Throughout the inspection residents offered the inspector drinks and made them. One resident said that they can choose what they want to eat, but they have to make sure they have some vegetables and fruit. Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 16 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): 19, 20 Residents can expect that their physical and emotional health needs are met. Residents can be assured that they may retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Two residents records were viewed, these showed the residents individual health and emotional needs. Correspondence and appointments were in place in residents records viewed. One resident spoken to has specific dietary requirements, the resident explained what they can and can’t eat and why. The resident was very clear on their health needs. The resident informed the inspector of regular health checks they attend and what happens at them. The resident confirmed that they bake their own foods and shop for food items, which they can eat. This shows that the resident is consulted with and supported in taking responsibility for their health needs. The manager confirmed that one resident had an optical appointment due for the following weekend; a member of staff confirmed this. One resident spoken to uses spectacles, these were observed to be clean. The resident said that they have their eyes checked when they get a letter from the optician.
Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 17 Residents records viewed had daily progress records showing the day-to-day activities and well being of the residents. This shows that health and well being is monitored on a day-to-day basis. The manager confirmed that two residents choose to administer their own medication. Residents who choose to do this, store their medication in a lockable drawer in their bedroom, and have a record where they tick when they have taken their prescribed medication at a particular time. The homes procedure was viewed. One resident spoken to said that they didn’t wish to look after their medication as they forget to take it and like staff to look after it for them. One staff file viewed held a certificate for medicines and record keeping. Residents records viewed showed what medications residents take. Medication records were viewed and staff signed for all medicines administered to residents. The manager confirmed their knowledge of storage and keeping of medicines in the home. Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 18 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): 23 Residents can expect to be protected form abuse, neglect and self-harm. EVIDENCE: Two residents spoken to said that if they were worried about something or felt unsafe, they knew that they could go to the manager of staff. One resident said that ‘the manager looks after me and makes sure I am safe’. The residents spoken to confirmed that they felt safe at Bailey Close. One resident said they have been ‘too trusting’ of people when they lived alone, but the manager has helped to learn about protecting themselves. One resident records looked at kept a record of all financial in goings and outgoings. The manager stated that payments are now made through direct debit, but they still keep a record of a residents finances. Policies, which were viewed, include abuse and the use of restraint. One staff record viewed contained a criminal records bureau check. Staff spoken to stated that they had received training on issues of abuse in their TOPSS (now Skills for Care) induction course, and thinks that it will also be included in their foundation course, which they will be undertaking shortly. Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 19 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): 26, 28 Resident’s bedrooms promote their independence and shared spaces complement and supplement resident’s individual rooms. EVIDENCE: Three residents showed their bedrooms to the inspector. All bedrooms provided required furniture, a hand washbasin and a lockable storage space. One resident unlocked their bedroom door with their own key, they confirmed that they keep their own key and make sure their bedroom door is locked when they are not in there. Residents bedrooms viewed were very different from each other and reflected their interests and personality. Residents provided information of when they bought items of bedding, pictures, and other contents. All bedrooms had photographs of family and friends. One resident had a weaving loom in their room where they make rugs. Residents confirmed that they chose the décor of their room. Bailey Close has a staff sleeping in room, which is locked when staff members are not present. Staff can store personal belongings in the sleeping in room.
Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 20 Bailey Close has an attractive garden area, which one resident stated that they take care of. The garden has a seating area, which has a shade to protect those wishing to sit in this area from the sun. There is a lounge area, with comfortable seating and a television. The lounge has lots of ornaments and memorabilia; the room has a very homely feel. One resident said that they could have visitors in this room in private if all other residents are in agreement. The dining and kitchen area are combined, there is a large dining table with sufficient seating for all residents and staff on duty. The kitchen area is domestic in nature. The laundry room is on the first floor; this room provides shelving, a washing machine and a drying machine. Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 36 Residents can expect to benefit from clarity of staff roles and responsibilities and be protected by the home’s recruitment policy and practices. There are shortfalls with respect to the qualifications and supervisions provided to staff. EVIDENCE: Two staff records viewed showed job descriptions for their support worker role. One staff member spoken to confirmed their job role and clearly was aware of the expectations of their role. The member of staff spoken to demonstrated knowledge of why they may need to seek advice from the manager or other professionals when supporting residents. The member of staff showed a clear knowledge of the residents they support. One member of staff spoken to had recently been employed at Bailey Close, they confirmed that they had completed their TOPSS induction course and was working on the induction ‘work book’. The member of staff said that they were starting a foundation course shortly and will then go on to work on their NVQ level 2 award. The manager confirmed this. The manager stated some concerns that some staff do not wish to complete their NVQ award. The registered manager should consider how they will support staff in achieving their NVQ award in order to meet targets of 50 of staff to have achieved at least NVQ level 2 by 2005. Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 22 Positive interaction between residents and staff was observed. Discussions between the manager and staff on duty involved all residents present. One staff record of a newly appointed member of staff was viewed. The record held a completed application form, training certificates, which included appointed persons emergency first aid, manual handling, medicines and record keeping and food and hygiene, two written references, a criminal records bureau disclosure, job description, contract, terms and conditions and copies of birth certificate and passport. This shows that the homes recruitment practices are sound. The manager was spoken to and has a clear understanding of requirements of recruiting staff to work at Bailey Close. One member of staff spoken to stated that the manager will and does support them in any training they identify to support their work role. The member of staff stated that they have had one formal supervision while working at Bailey Close; they said they feel supported by the manager and speak to them on a daily basis. Daily handover meetings and staff meetings offer further support to staff. The record of the supervision was viewed, the manager sought clarification that this is how supervisions should be recorded, the manager confirmed that staff are provided with informal discussions regularly. Staff should have regular, recorded supervision meetings at least six times a year. Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 Residents can expect to benefit from a well run home, but there is a shortfall regarding the management qualification of the manager. Residents can be assured that they can benefit from the ethos, leadership and management of the home. EVIDENCE: The manager at Bailey Close currently holds a registered nurse qualification; they still need to achieve the NVQ level 4 in management. Evidence was viewed that the manager has corresponded with Suffolk Partnership with an aim to achieve their NVQ level 4 in management. The manager confirmed that there have been some issues, a place was identified for the manager for this course but changes in the provider bought problems for the manager with funding and transport to the nearest college. The manager confirmed their understanding that they must meet the requirement of achieving an NVQ level 4 in management by 2005. The manager was spoken to and has a clear understanding of their role, as do the staff and residents spoken to at the time of the inspection. The manager
Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 24 provides a clear sense of direction and leadership to the home. One staff member spoken to stated that the manager is easy to talk to and feels confident that they can be approached at any time. The staff member had a clear understanding of the aims of the home. The member of staff stated that they are happy and work and that Bailey Close is a ‘stress free’ environment. The atmosphere and positive relationships at Bailey Close are provided with the input of the management style of the home. Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 X X Standard No 24 25 26 27 28 29 30
STAFFING Score X X 3 X 3 X X LIFESTYLES Standard No Score 11 4 12 4 13 3 14 4 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 X 3 X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Bailey Close Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 3 X X X X X DS0000024329.V253155.R01.S.doc Version 5.0 Page 26 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 YA36 Regulation 17(2) 18(2) 9(2)(b)(i) Requirement The registered person must ensure that staff supervision is recorded and retained on their records The registered manager must evidence how she proposes to meet the requirement of an NVQ level 4 in management by 2005 Timescale for action 21/09/05 2 YA37 21/09/05 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 Refer to Standard YA33 Good Practice Recommendations The registered person should consider how she will meet the requirement for 50 staff with NVQ 2 by 2005 Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Bailey Close DS0000024329.V253155.R01.S.doc Version 5.0 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!
