Inspection on 28/02/06 for Barron Winnicott Unit

This inspection was carried out on 28th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Barron Winnicott Unit 22/03/05

Barron Winnicott Unit 16/04/04

Similar services:

5 Seafield Road

Honeybourne House

Longrun House

Bodley Community Care Support Centre

Thomas Pocklington Trust

Chantry Gardens

Penkelly House

25-27a Alexandra Road

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

CARE HOME ADULTS 18-65 Barron/Winnicott Unit RNID Poolemead Centre Watery Lane Twerton Bath Bath & N E Somerset BA2 1RN Lead Inspector David Smith Unannounced Inspection 28th February and 10th March 2006 09.30 Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Barron/Winnicott Unit 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) RNID Poolemead Centre Watery Lane Twerton Bath Bath & N E Somerset BA2 1RN 01225 332818 RNID Ms Daphne Ann Dibben Care Home 11 Category(ies) of Sensory impairment (11) registration, with number of places Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 11 persons aged 18 - 64 years, requiring personal care. 20th September 2005 Date of last inspection Brief Description of the Service: Barron Winnicot Units are situated on the first floor of the central Poolemead building and provide support and care for adults with a single or dual sensory loss, and associated learning disabilities. The building is divided into two distinct areas, Barron and Winnicot, with 10 bedrooms in total. Each separate area has a lounge, kitchen and dining space. There is no structural barrier between the areas, but each provides for a specific group of service users and retains its own identity. Service users have access to the grounds, which include well-kept attractive gardens. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over two days. The inspector gathered information for this report from discussions with the Manager, Deputy Manager, four staff members, observations of communication and interaction between staff and service users, inspection of care plans and other records and a tour of the home. What the service does well: What has improved since the last inspection? A Service Users guide has been developed using the widget symbol system. This has provided five service users with access to this information. Staff awareness of the POVA procedure has improved. This helps ensure the welfare and safety of service users. The management of service users’ finances has improved. Two staff are now required to sign records and this provides a more secure system to support service users. Regular fire drills are now conducted and a record is maintained. This helps promote the welfare and safety of service users and staff. Criminal Record Bureau disclosures are now obtained for all staff prior to commencing employment. This forms part of a robust recruitment practice to protect service users. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 6 What they could do better: A review of the quality of care has identified numerous areas for service improvement. Once this development plan is completed the service provided should improve for each service user. The strategy for improvements within the service should be prioritised and demonstrate that these are effectively planned, are realistic and can be reflected upon. This will help to ensure an improvement in service delivery. The management team must show clear leadership in the delivery of consistent care for each service user and support for each member of the staff team. Organisational monitoring and support of the service needs to improve. This will help promote the safety of service users, improve service delivery and support the management team within the home during a time of significant development and change. A copy of the service users contract between the RNID and the service user must be made available to the manager. Care plan reviews need to be carried out 6 monthly for each service user. The outcome of such reviews needs to be recorded. Staffing levels must be kept under review to ensure service users choices or opportunities are not being unnecessarily limited. The home specific medication policy should be the subject of a review. This will help ensure the welfare and safety of service users. All staff must receive formal induction training within the timescales defined by the organisation. This will ensure staff are provided with the necessary skills to support service users. All staff must be supervised on a regular basis and a clear, signed record of each meeting must be maintained. This will ensure all staff are supported to provide support the service users. Weekly tests of fire equipment need to be maintained. This will promote the safety and welfare of service users and staff. The home should review its progress in providing service users with information in a format which is accessible to them. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 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. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 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 Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 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): 1 and 5. Prospective service users are provided with relevant information to enable them to make an informed choice of where to live. This information must be updated regularly. There are contracts in place between the service users and RNID but not between the RNID and Funding Authorities, as there need to be. This remains an outstanding requirement from previous inspections but because compliance with this requirement is outside the control of the manager it is being raised with the Commission for Social Care Inspection’s Provider Relationship Manager as a national issue. EVIDENCE: The home’s Statement of Purpose contains all information as outlined in the National Minimum Standards. This was last updated in January 2006. The document is well presented, although slight amendments are now required. The staffing profile should be amended as there have been changes within the staff team and the contact details for the CSCI inspector should now be amended. The service users guide has been adapted into the widget format. This has been shown to five service users who have signed to confirm they have seen Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 10 this document. The home hopes to develop guides for each service user in the future. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 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 and 9. Care plans are reviewed and updated annually. Service users are supported to participate in this process. This process should be improved to ensure all care plans are reviewed at least every six months. Staff provide service users with information and encourage them to make informed choices wherever possible. However, this needs to reflect the skills and abilities of each service user. The Risk Assessment process supports each service user to maintain an independent lifestyle. EVIDENCE: Two service user care plans were examined and these provided detailed information on the areas of support each person required. Annual reviews are held, which include service users, their families, Social Workers and Keyworkers. These are clearly recorded and the outcomes used to update individual care plans. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 12 There was no evidence to confirm that each care plan was reviewed at least every six months. Discussions with the manager and senior staff confirmed this process is not consistent within the home. This remains an outstanding requirement from the last inspection. During the course of the inspection the inspector observed interaction, communication and support between the staff team and service users. This demonstrated staff have a good knowledge of service users support needs, individual behaviours and how to communicate effectively with them. Various forms of communication are used to enable service users to make choices. The inspector observed British Sign Language being used. There are also pictures/picture symbols in use and some information has been adapted into the Widget format. Some staff members were concerned at the current approaches in providing information/choices for service users. It is felt that at times some service users are overwhelmed by the number of choices made available to them. For example, providing a catalogue containing fifty similar items when the person can only reasonably choose from three or four items. This can lead to confusion, withdrawal from the activity or occasionally challenging behaviour. Support for each service user should be provided using a person centred approach. This should developed to ensure each service users skills, abilities and support needs are recognised. The home should also consider how each service user can access information in a way which is meaningful to them. There are person centred Risk Assessments in place for service users. These provide clear information and there is evidence that they are regularly reviewed and updated. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 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 and 15. Service users are able to take part in appropriate activities with the support of the staff team. Service users are supported by staff to use facilities both within the Poolemead site and in the wider community. They are also supported to enjoy holidays, visits to family and friends. However, staffing within the home needs to be reviewed to ensure service users do not have their opportunities unnecessarily limited. One service user is currently being supported by to gain a greater understanding and the opportunity for personal development in personal relationships and sexuality. EVIDENCE: Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 14 Service users have the opportunity to attend daily Educational Development Studies. Facilities available in the wider community are also used, including horse riding, going for walks, shopping, going on holiday, trips to local pubs and going out for meals. Each service user has opportunities to learn and use practical life skills, and this is evident in the way they participate in daily occurrences within the unit, including housekeeping and cooking responsibilities. Records show that service users visit their families and that they are supported to choose, organise and attend holidays. One service user has demonstrated both through discussions with staff members and his own actions that he requires support with personal relationships and the expression of his sexuality. The home has accessed an external professional to support the service user in this area. Staff spoken with explained that two service users have 1:1 support. The other eight service users are normally supported by four staff. These staffing levels do appear to restrict opportunities, especially when relief staff are on duty. The staffing levels maintained within the home should therefore be reviewed to ensure that all service users are offered opportunities and appropriate support to enable them to enjoy a range of activities, both within the home and in the wider community. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. A monitored dosage system of medication for service users is in operation and this is generally well managed but all staff should receive accredited training in medication administration and the home specific policy regarding medication administration should be subject to review. EVIDENCE: The home’s medication procedures were inspected by the Commission’s Pharmacy inspector in November 2005. The outcomes of this inspection and action taken by the home were therefore focused upon as part of this inspection process. The medication administration in relation to the Barron unit was inspected. The home uses the Boots monitored dosage system of medication. The medication records show profiles of each service user, recent photograph, details of their medication, times of administration and manufactures notes on each of the prescribed medications administered within the home. Two staff are required to check the medication administered to service users and sign the appropriate records. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 16 All staff are currently being retrained in medication administration within the home. This process should be completed shortly. The inspector was advised that a number of staff have recently commenced external medicines training, which is being provided by the City of Bath College. However, no records were available relating to this training course on the day of inspection. The manager has produced a comprehensive home specific policy relating to medication administration. A copy has been provided to the Commission. The inspector discussed this policy with each member of staff consulted as part of the inspection process. Whilst all staff appeared to welcome this development, no member of staff was confident that they could remember or explain all of this policy. Each staff member expressed the opinion that this policy was far too detailed and contained too much information to be an effective or user-friendly document. Some staff felt under pressure to adhere to this policy and rather than leading to an improved/safer process for service users, mistakes were still being made due to the pressure. Medication errors had occurred prior to the current manager being appointed. All medication errors are now reported to the Commission in accordance with the Regulations. Continuing reports to the Commission of medication errors would appear to support the views of staff. Whilst the inspector commends the development and implementation of this policy, it appears this does require review. This process should be conducted taking into account the views of the staff responsible in managing medication on a daily basis to help ensure any amendments to the existing policy lead to a clearer and safer system to support each service user. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The complaints policy and procedure is clear and effective and there is every indication that service users feel their views are listened to and acted on. The staff team are provided with training and support to ensure the welfare and safety of service users. Clear reactive strategies and Risk Assessments are in place for each service user who presents challenging behaviour. These must be subject to regular review to ensure the welfare and safety of each service user. EVIDENCE: There is a clear complaints policy and procedure, in symbol format for service users. All staff consulted were aware of the procedure should a complaint be made by service users while they were on duty. The records examined showed a concern was raised by one service user relating to an incident, which occurred whilst visiting a family member. This incident was discussed with the service user and a record, written in a style the service user could understand, was evident. It appears that the home acted in this service users best interests and in accordance with policy and procedure. The Protection of Vulnerable Adults and NAAPI training are both part of the core training programme for staff employed by the RNID. The training matrix confirms that staff have attended these training sessions. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 18 Staff spoken with were able to explain the action they would take if they either suspected or witnessed abuse whilst on duty. This was in accordance with the home’s policy. There is a Criminal Records Bureau disclosure for each member of staff on file and the log record was updated by the inspector. The home has clear guidelines and risk assessments in place for supporting service users who are distressed or presenting behaviours which may be perceived as challenging the service provided. These were subject to review. These guidelines, however, should be included in the six monthly care plan review process still to be adopted by the home. This process should also include a review of recorded incidents. The manager expressed her concern regarding inconsistent responses to some incidents of challenging behaviour. This process may identify improvements in work practice and help to ensure consistent support for each service user. These measures would help to ensure the welfare and safety of each service user is being actively promoted. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 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): 24 and 30. Service users live in a homely and comfortable environment. The units are clean and hygienic. EVIDENCE: The inspector was provided with a tour of all communal areas within the home. Both units were clean and tidy on the day of inspection. All furnishings and fittings are of good quality. A number of pieces of service user artwork are displayed throughout the home, together with several photographs. New carpeting has been laid in both communal corridors and these areas have also been redecorated. A cleaner is employed to clean communal areas, which is outside of the service users’ housekeeping responsibilities. She was seen working in the home on the day of inspection. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 and 36. Service users are supported by a competent and committed staff team. However, both the consistency of support for service users and the morale within the team must be monitored and improved upon. There is an excellent staff training and development programme in place, but consideration should still be given to racial equality and mental health training being provided for all staff. Training must be provided consistently to all staff. Staff supervision needs to be provided consistently. A clear record of each supervision meeting must be maintained. EVIDENCE: The inspector spoke with five members of the staff team during the inspection process. Each staff member confirmed that although they enjoyed working in the home, there had been a number of changes recently introduced in an effort to improve the support for service users. There was a general feeling amongst staff that too many changes were being implemented too quickly. This had led several staff feeling under pressure, unsure of their current work practice, no longer valued and some considering finding alternative employment. One senior member of the staff team had Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 21 recently left the home, but there is no evidence her departure was related to these issues. Staff spoken with confirmed they attempt to raise their views at both supervision meetings and team meetings. This does not always appear successful as some staff feel their views are not acted upon. All staff recognised that good morale was a key factor in providing support for each service user. They appeared genuinely committed to improving the service but concerned that morale was being adversely affected by the pace/number of changes. It was evident that the home had also suffered recent staff shortages, which had led to occasional tensions within the team, inconsistent approaches in supporting service users and had affected their opportunities. During the inspection the inspector observed one service user who had become very distressed while out in the community. The manager worked hard to support him on his return to the home. It became apparent that his distress had been caused by staff failing to ensure he had sufficient funds to complete his shopping. It was unclear what planning had taken place prior to the shopping trip or exactly what had been communicated to him whilst out. The manager explained that this example of inconsistency/lack of planning did occur frequently and this was an area she was attempting to address with the staff team. Several new staff have now been recruited and are soon to commence employment. Once this is completed staff are confident that this will again improve the support and opportunities for each service user. There are excellent training opportunities available for staff. Training records show that staff have completed all statutory training, induction, which includes health & safety, and other relevant training, autism awareness, diabetes, and NAPPI. Training on mental health and racial equality have not been made available to all staff. The inspector did note that core training had not been provided to all of the relief staff. These staff members work on a casual basis but could solely support service users in the community. The home should review the training and support for relief staff to ensure they are appropriately trained to support service users. The home monitors staff training by using a training matrix. This was last updated in February 2006. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 22 The inspector could not assess the progress in the home supporting staff to gain National Vocational Qualifications, as the training matrix had not been completed in this area. This will be focused on during the next inspection. Staff are supervised by senior members of the team. Most staff are provided with regular supervision meetings, but some staff are still not being supervised regularly. This needs to be provided more consistently to ensure that all staff are provided with support to both perform effectively and understand the changes being made within the home. A template exists to record supervision meetings. This had not been used to record some meetings and the inspector found it difficult to ascertain exactly what had been discussed and what the outcomes of the meetings had been. A clear record of each meeting needs to be maintained and the use of a template is good practice. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 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, 42 and 43. A new manager is now in post. New management procedures are being implemented in an effort to improve service delivery. The pace/number of changes is causing concern. Organisational support of the service should be improved to support service users and staff through a period of significant change. Although the health and safety of service users and staff is well promoted, the fire alarm system must be checked on a weekly basis. EVIDENCE: The current Manager has only been in post for a few months. The Commission are considering her application to be registered under the Fit Persons Process. Since her appointment she has attempted to address and improve several management issues, together with the Requirements and Recommendations from the Commission’s last inspection report. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 24 The recent quality assurance audit of the service confirms that several improvements are planned and timescales have been fixed. This document has been produced by the manager in partnership with her line manager. These improvements appear well intentioned and are focused on improving the service provided to each person who lives in the home and providing staff with clearer policies, procedures and practices to support this process. However, through discussions with the manager and members of the staff team it is not clear that the pace/number of changes are realistic or manageable. Also, staff do not generally feel there is an inclusive atmosphere in the prioritising and planning of these changes. The senior members of the staff team will need to play a leading role in supporting and managing the team through a significant period of change. It is not apparent at this stage that they agree with all of the planned changes, the pace of change, the lack of staff consultation and opportunity to reflect of the processes/success of change. These views have been shared with the Residential Services Manager, however this does not appear to have altered the plan of development or the anticipated timescales. This has added to the concerns of some staff. The number and the pace of the changes are leading to inconsistencies in the approaches and support being provided to service users. Staff do not appear confident that their current working practices are in accordance with the new policies or procedures, as they currently have to absorb large amounts of information, which some staff have said is “overwhelming”. Staff spoken with welcome discussions or proposed improvement to the service. They do feel this process should include both service users and staff views. They also feel that these must be better planned and the changes be staged over a period of time rather than occurring simultaneously. Each change must be reflected upon and its success in leading to improvement be measured in some way. The inspector concurs with the views of the staff consulted as part of this inspection process. The manager also accepts that the development plan should be reviewed, as this was devised when she had only been in post a short while. It is now apparent that all of the key objectives cannot be met within the next 12 months. It is acknowledged that the staff team need to feel included in this process and that the views of service users must also be sought. There are a number of generic Risk Assessments in place to ensure the welfare of service users and staff. These had all been subject to recent review. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 25 All incidents, accidents and injuries to service users have been recorded and were stored appropriately. The fire log provided evidence that regular fire drills are now being conducted. The fire fighting equipment is regularly checked and a record maintained. There were some minor gaps in the weekly testing of the fire alarm system. This should be checked each week in accordance with the Avon Fire Log guidance. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 26 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 2 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 2 2 X X X 2 2 Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement The Statement of Purpose must be updated to comply with National Minimum Standards. All care plans must be reviewed and updated every six months. A clear record of the review process for each service user must be maintained. Staffing levels to be reviewed to ensure service users opportunities are not unnecessarily limited. Behavioural Management strategies must be subject to regular review. All staff must be provided with training which meets all RNID core standards. All staff must be provided with training which provides all staff with additional relevant skills to support service users. Timescale for action 28/04/06 2. 3. YA6 YA6 15 15 28/02/06 28/02/06 4. YA33 18(1) 28/05/06 5. YA23 13(6) 28/02/06 28/05/06 6. 7. YA35 YA35 18(1) 18(1) 28/08/06 Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 28 8. YA36 18(2) All staff must be provided with regular supervision and a clear record maintained. The development/improvement of the service must: a) Take into account the views of service users and staff. b) Be supported by an achievable development plan. c) Include appropriate organisational support and monitoring. 28/02/06 9. YA38 12(3) 12(5) 24(3) 28/05/06 10. YA42 23(4) Regular checks on the fire alarm system must be maintained and recorded. Develop and support a management team who can motivate and lead by example. 28/02/06 11. YA31, 33, 38 18, 19 28/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA20 Good Practice Recommendations The home should review its progress in providing information in accessible formats to each service user. The home should review its home specific medication administration policy. Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Barron/Winnicott Unit DS0000040664.V284054.R01.S.doc Version 5.1 Page 30 - 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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