Inspection on 09/01/07 for Ballards Ash Farm

This inspection was carried out on 9th January 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ballards Ash Farm 14/11/05

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 Ballards Ash Farm Ballards Ash Farmhouse Brinkworth Road Wootton Bassett Swindon Wiltshire SN4 8DS Lead Inspector Pauline Lintern Key Unannounced Inspection 9th January 2007 10:00 Ballards Ash Farm DS0000063486.V324391.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 Ballards Ash Farm DS0000063486.V324391.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. Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ballards Ash Farm Address 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) Ballards Ash Farmhouse Brinkworth Road Wootton Bassett Swindon Wiltshire SN4 8DS 01793 840807 Choice Limited Mrs Barbara Ann Wild Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2005 Brief Description of the Service: Ballards Ash Farm is one of a number of homes owned and managed by Community Homes of Intensive Care and Education (CHOICE). The home is situated on the outskirts of Wootton Bassett and accommodation comprises of nine single bedrooms with en suite facilities. Ballards Ash provides medium to long-term care to adults with learning disabilities and complex needs. The home accommodates younger adults of either sex, whose maximum age does not exceed twenty-five. The aims of the service are to promote the rights of residents in a secure, supportive stimulating and homely environment. There is a minimum of four staff on duty throughout the waking day, in addition there are two waking night staff. Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection was completed over six hours. The manager Mrs Wild was present throughout the inspection and assisted the inspector. The operations manager was present when the inspector provided feedback at the end of the inspection. The inspection involved examination of two service user’s care plans and risk assessments. Staff recruitment records, training records, complaints records and health and safety records were also sampled as part of the inspection process. The inspector was able to meet with two service users to discuss whether they are happy with the service that is being provided for them. The inspector was able to communicate with one service user using their preferred method of communication. There was the opportunity for the inspector to meet with staff in private to obtain their views. The training provider was present for part of the inspection and met with the inspector to share her comments. Five survey forms were sent out to service users and five to their families. Three service users’ surveys and five relatives surveys were returned to us. All five surveys from relatives stated that they are happy with the service provided. Comments included were ‘ I find Ballards Ash a very friendly, happy home. The staff are all helpful and my relative has settled in very well there’ and ‘I’m very impressed with the way the house is managed and developed from it’s opening up to the present’. Two care managers were asked for their comments and both responded positively. The fees charged at Ballards Ash are £1,700 per week. What the service does well: The service has a manager with a ‘hands on’ approach and an open door policy. Service users are welcomed into her office to chat or just to sit with her if they wish. The home has excellent systems in place to review individual’s care plans and provide the reader with a good understanding of what is important to the service user. The management of emotional needs is commendable with plenty of information, guidance, monitoring and support mechanisms in place. Specialist input and guidance is available to ensure that the service users needs are being met. All staff are trained in physical intervention techniques and attend regular updates. Medication is managed and recorded well. The induction package is comprehensive and ensures that all areas are covered for the new member of staff. The training programme provides all mandatory training and specific training is also accessed to widen the staff’s knowledge. Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 6 Recruitment records examined showed that all checks and documents are sought before a position is offered. The home is signed up to the local protocols for reporting any suspected abuse and staff demonstrated knowledge of the procedure. Staff are able to use appropriate communication skills to meet service users needs. 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. Ballards Ash Farm DS0000063486.V324391.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 Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users and their families are provided with adequate information for them to choose if they wish to live at the home. Service users needs are individually assessed to ensure the home can meet their needs. EVIDENCE: Three out of three service users surveys report that they were asked if they wanted to move to the home and were provided with enough information to help them reach this decision. Records show that following the initial assessment a review meeting takes place to monitor the transition process. There are follow up meetings at six months and again at 12 months. The assessment covers likes and dislikes, communication, domestic skills, life changes, relationships, health and current medication, sexuality, self help skills, physical and emotional health, risk assessments and leisure. There is evidence that topics such as finance and key workers are also discussed. Each person has a service user guide, which includes information on how to make a complaint. They are in pictorial format and state that the service user guide is also available on audio if required. Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 9 There is evidence that the manager or key worker will sit and explain the contents of the service user guide individually with people if they wish. A current statement of purpose is available. Ballards Ash Farm DS0000063486.V324391.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): 6, 7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Individual plans reflect the needs of the service users. Staff members support service users to make decisions about the way they live their lives. Measures are taken to minimise any potential risks to service users. EVIDENCE: Two individual care plans were examined as part of the inspection process. Both plans reflect the completed assessment and detail how the home will meet the person’s needs. Care plans are reviewed on a monthly basis by the key worker and cover day services, family contact, behaviours, communication and personal care needs. Care plans include information on cultural needs, eating and drinking, health, medication, mobility, personal hygiene, sexuality, spirituality, work and leisure. Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 11 Care plans are in a format to suit the service users needs, such as using pictures and large print. There is evidence of the involvement of the family, care manager, psychologist and the service user in the development of their individual plan. There are good systems in place to ensure that care plans are regularly reviewed and updated. There is guidance on how to support people to make choices and decisions regarding their life. Many of the staff are able to use sign language, which enables them to provide service users with information, assistance and communication support. The manager reported that they are looking at further training in sign language for the newer staff. One new staff member confirmed that they had previously learnt the basics of British sign language and had gathered more resources to update their knowledge. Two out of the three service user’s surveys report that two feel that they ‘always’ make decisions about what they do and one person said that they ‘sometimes’ make decisions themselves. Five out of five surveys returned to us from relatives confirm that they all feel that they are kept informed of important matters and are also consulted if their relative is not able to make decisions about their care. One comment received stated that ‘ they are excellent at keeping me informed either by email of a telephone call’. Service users have a risk management plan, which demonstrates how potential risks will be managed. These are also kept under review. Mail is given to the service user and staff will support them to read it if required. Service users have the opportunity to receive visitors in private and can make and receive telephone calls in private if they wish. Ballards Ash Farm DS0000063486.V324391.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): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users have access to appropriate activities. Staff support service users to access the local community. Service users are encouraged to maintain relationships and friendships. Staff members ensure that service users are treated with respect and dignity. EVIDENCE: One service user file showed that they attend college full time where they learn computer skills, literacy, cooking, singing and accessing the community. Service users also enjoy attend ‘music alive’ and the home has arrangements for a music therapist to visit the home once a week. The manager confirmed that they have recently appointed a day services organiser. This person had placed a photograph of themselves with some Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 13 information about them on the notice board to introduce themselves to the service users. Each person has an activity plan for the week, which shows that service users have the opportunity to attend many activities. These include computer skills, cinema, bowling, and swimming, keep fit, walking, shopping, music, DVD’s and cooking. Staff confirmed that service users have the opportunity to go on holidays and this year there have been trips to the Calvert Trust where one person enjoyed rock climbing, another holiday to the Peak District and another to Butlins. The home is exceptionally well equipped with a separate sensory building, which is positioned away from the main house. At the time of the inspection three service users were using this facility with staff support. They also have a activities room, complete with plenty of desk/work area and there is a new ‘touch’ screen computer. The garden has a large trampoline and also a swing for service users to use. The manager reports that all of the people living at the home like to spend time outside in the summer where they have their meals, can enjoy barbeques and play football if they wish. The manager has plans to make part of the garden into a sensory plot for service users to be able to access. It was noted that one service user has a go-cart that is kept in the garden. The manager explained that they are in the process of purchasing a larger and more appropriate vehicle for the home, which will be beneficial as more people can go out if they wish at the same time. One staff member reported that service users enjoy just going out for a ride in the car some days. Three out of three surveys confirmed that service users are able to do what they want during the day, in the evening and at weekends. Service users are able to attend church if they choose. Staff receive training in values and attitudes, which enables them to understand individuals rights and how to promote independence for service users. During the inspection staff were observed treating people respectfully and with dignity. Care plans inform the reader of the service user’s preferred form of address. The manager confirmed that service users have a key to their bedrooms although they do not always use them. The individual care plans state that service users are not expected to clean the home however they are encouraged to participate in activities such as cooking and keeping their rooms tidy. The home provides unrestricted access for service users, excluding people’s bedrooms. It is clear that service users feel comfortable around the staff and like to spend time with them. As stated earlier the manager has a ‘open door’ approach, which enables service users to access her office when they wish. The interaction between service users and staff members is very positive. The home has a cook who prepares and provides meals for service users. The menu appeared varied and nutritional. The manager reported that the food is of a high standard. At the time of the inspection the fridge and freezer was very well stocked with provisions. There was a plate of homemade cakes in the kitchen, which the manager reported was made by a service user. The home Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 14 has a comfortable dining room for service users to enjoy their meals with three separate tables. Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Support with personal care is delivered in a way the service user prefers. Emotional and physical needs are met and monitored. Medication policies and procedures protect service users where possible. EVIDENCE: Each care plan sampled explains how the person prefers to receive their personal care support. There is clear guidance on morning and evening routines to ensure that staff carry out tasks appropriately. One file sampled reminds staff that to ensure that the person is treated with respect and dignity, they should have a male member of staff to assist them where possible. Service users have a Health Action plan, which states how staff can support them to maintain good health. All service users are registered with a general practitioner and attend check ups at dentists and opticians. Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 16 There is access to other health care professionals such as speech and language therapists, psychiatrist and psychologists. Service users have a psychology report, which is kept under review to ensure that results are evaluated. The mechanisms for monitoring, managing and recording behaviours is commendable. There are clear guidelines for staff to follow, which identify triggers, distraction techniques and ways of preventing the display of behaviours. All behavioural observations are recorded. One staff member confirmed that since they have opened, the behaviours displayed by some service users has greatly reduced through good management. Medication appears to be managed well. Records were sampled and no gaps were found in records. All ‘as required’ medication is recorded and there are individual guidelines on service users care plans. A medication stock check is completed weekly. There is a list of staff names that are trained to administer medication. Each service user has a medication assessment and guidelines in place. It is recommended that a photograph of each service user is placed on the front of their medication record to ensure their identity. It would be good practice to obtain a list of staff signatures, to help identify who has signed the medication sheet. The manager explained that on the day of the inspection some staff were attending training on epilepsy and the medication Midasolam as it is relevant to the service user group. In line with good practice the home are keeping this medication securely double locked. Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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 using available evidence including a visit to this service. Service users feel that their views are listened to and acted upon. Service users are protected from abuse where possible. EVIDENCE: Each service user guide has a copy of the complaints procedure, which is in a pictorial format. The two files sampled showed that the manager has explained the complaints procedure with the service user to ensure they understand. The three service user surveys returned to us confirmed that they all know who to speak to if they are not happy but reported that they do not know how to make a complaint. Four of the relative’s surveys state that they have never had to make a complaint. The home’s complaints policy states that any complaints will be responded to within 28 days. The complaints log shows that this timescale is adhered to. The manager confirms that there has been four complaints in the last twelve months and none were substantiated. All were responded to within 28 days. Staff members who spoke to the inspector demonstrated a sound understanding of the procedures to follow if they suspected any form of abuse. All staff are given a copy of the Wiltshire and Swindon guidance ‘No Secrets’ and all staff attend training in abuse awareness. In the last twelve months Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 18 there has been one Protection of Vulnerable adults referral (POVA), which was dealt with appropriately by the home. Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The accommodation is of a high standard. The home is clean, hygienic and safe. EVIDENCE: The property provides a high standard of accommodation. Each bedroom has an en suite facility and a walk-in shower. One service user commented ‘I like my bedroom, it is beautiful’ and ‘I like the house, I am happy’. Each room is decorated to a high standard with good quality furnishings. At the time of the inspection, the home was clean, tidy and free from odour. On the top floor of the property there is a large room, which can be used for meetings and training and a smaller room where staff supervisions are held. There is a large enclosed garden to the rear of the property, which is secure. There are laundry facilities situated on the ground floor away from any food preparation areas. There is a commercial washing machine and tumble drier. Red alginate bags are used to transport soiled washing to the laundry. The laundry area was found to be clean and hygienic. Staff are provided with Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 20 protective clothing such as gloves and aprons when needed. Records demonstrate that staff receive training in infection control. Ballards Ash Farm DS0000063486.V324391.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): 32, 34, 35 and 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff in the home are trained and in sufficient numbers to support the people who use the service. The home’s recruitment procedure protects service users where possible. Staff receive supervision although some need to be more frequent and need to be recorded and dated. EVIDENCE: There is sufficient staff on duty to enable them to meet the needs of the service users. During the night there are two waking staff on duty. 100 of the relatives surveys returned to us confirm that they feel there is sufficient staff on duty to meet the needs of the service users. The home offers a very comprehensive induction package for new staff members. Some of the areas covered in the induction training include: health and safety, reading policies and procedures, protection of vulnerable adults (POVA), medication, the role of the key worker and daily records. One staff member explained that they had worked through the workbook as part of their induction and confirmed that the ‘training is good’. Staff training records and Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 22 the training programme shows that staff are offered training in various subjects such as anti-discriminatory practice, health and safety, manual handling, fire awareness, basic food hygiene, self injurious behaviour, breakaway techniques, positive and negative reinforcement, abuse awareness, religious and cultural needs,, autism, epilepsy, values and emergency first aid. The manager confirmed that at present eight staff hold a current first aid certificate and 51 of staff have achieved their National Vocational Qualification level 2 or above. The manager explained that qualified paramedics provide all training in first aid and qualified mental health nurses deliver training in manageing behaviours. Staff members were observed using appropriate communication skills with service users. One staff member explained that she had prior training in some basic sign language. Another staff member’s recruitment files show that they have experience of using signed communication. Four staff member’s recruitment files were examined, which provided evidence that recruitment procedures were satisfactory. Two references are sought and all staff are checked with the Criminal Records Bureau (CRB) and checked against the Protection of Vulnerable Adults (POVA) list before commencing employment. Any gaps in the employment history are explored and recorded to safeguard service users. The manager confirmed that staff meetings take place monthly. Staff members informed the inspector that they attend regular team meetings. Staff confirm that they receive supervision with their line manager. Records show that the regularity of supervisions needs to be monitored to ensure that staff have the opportunity to communicate with their supervisor on a regular basis and that the discussion is then recorded and signed by both parties. Ballards Ash Farm DS0000063486.V324391.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): 37, 39 and 42 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. Service users and their relatives have the opportunity to share their views on the service being provided. The health, safety and welfare of service users are protected where possible. EVIDENCE: The manager of the home has the required qualification and experience to manage the home. She has completed her Registered Managers Award and has an NVQ level 4 in care. Discussion with the NVQ assessor confirmed that they felt that the manager ‘has excellent systems/paperwork in place’. Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 24 Feedback received from trainers, relatives, staff members, service users and care managers states that the manager is ‘excellent’, ‘very supportive’, ‘always puts service users best interests first and will stand up for them’, ‘great communicator’ and that there is a ‘good team atmosphere’. The manager explained that she manages the home with an approach of ‘openness’. Service users were observed interacting well with the staff and manager and clearly feel at ease in approaching the manager at any time. The manager appears to have a good understanding of the training needs of the staff members and ensures that all staff have the opportunity to undertake training. On the day of the inspection the cook had joined care staff at a training course. A feature of the home is that they have monthly resident’s meetings. Minutes sampled show that service users are able to express their views using their preferred mode of communication. Service users were asked if they are happy living at the home, what other activities they may like to participate in, if they are enjoying college and how they find the food at the home. It was recorded that one person appeared tired and did not wish to take part in the meeting and so left the meeting. The home has a development plan, which has been developed following feedback from questionnaires that had been sent out to service users, their families and care managers. The health and safety in the home appears to be well managed. The health and safety risk assessment was reviewed on 1.9.06 along with all other generic risk assessments. All toxic materials are locked securely in the laundry room and there is a file containing all relevant data for staff members. There is a risk assessment for all toxic materials. The manager reported that they have had health and safety checks carried out by the insurance services on 28/08/06 and on 06/10/06 and everything was found to be satisfactory. The home carries out its’ own health and safety audit, which covers clinical waste, infection control and legionella. The home has a ‘legionella compliance’ certificate dated 22/7/06. The last inspection of food safety/food hygiene took place on 24/05/06. The manager confirmed that they receive training from the Fire Brigade annually. The manager also provides staff members with a questionnaire on fire procedures every three months to ensure that they are competent. The home has an evacuation procedure for both day and night hours. There is an current fire risk assessment in place. Records show that staff members receive fire instruction and complete regular fire drills. All relevant checks are made on fire fighting equipment and lighting. Door releases are also regularly tested. The fire officer last visited the home on 28/02/06. There is evidence that that specialist equipment is regularly serviced. Ballards Ash Farm DS0000063486.V324391.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 4 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 4 X 4 X X 3 X Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA6 YA36 YA20 YA20 YA20 Good Practice Recommendations It is recommended that all documents/records are signed and dated. It is recommended that staff receive regular supervision and that this is then recorded and dated. It is recommended that medication records have a photograph of the service users on the front to identify them. It is recommended that staff receive regular ‘in-house’ refresher training on administering of medication. It is recommended that there is a list of staff signatures to be kept in the medication file to identify staff that has administered medication. Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Ballards Ash Farm DS0000063486.V324391.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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