Inspection on 09/01/07 for Bartlett Close 1

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 (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bartlett Close 1 23/02/09

Bartlett Close 1 31/10/07

Bartlett Close 1 25/07/06

Bartlett Close 1 06/10/05

Bartlett Close 1 21/07/05

Bartlett Close 1 21/02/05

Bartlett Close 1 13/05/04

Bartlett Close 1 09/03/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 1 Bartlett Close Witney Oxfordshire OX28 6FD Lead Inspector Barbara Mulligan Unannounced Inspection 9th January 2007 10:30 1 Bartlett Close DS0000013063.V326140.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 1 Bartlett Close DS0000013063.V326140.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. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Bartlett Close Address Witney Oxfordshire OX28 6FD 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) 01993 709646 01993 709659 www.macintyrecharity.org MacIntyre Care Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2006 Brief Description of the Service: 1 Bartlett Close is home to four adults with learning and some physical disabilities close to the centre of Witney, a market town in West Oxfordshire. The home is managed by MacIntyre Care. The building is modern and purpose built to meet the needs of people with physical disabilities. Care is provided by a staff team, which aims to enable the service users to lead active lives and pursue their own interests in and out of the home. Fees range from £49,371 per annum to £54,542 per annum. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken on 9th January 2007 at 10:30am. The visit consisted of discussions with the Acting Manager, care staff and service users. A tour of the premises and an examination of the homes records, policies and procedures was undertaken. The inspection officer was Barbara Mulligan. The Acting Manager is June Brewer. Twenty-five of the Key National Minimum Standards for Younger Adults were examined. Nineteen of these are fully met and six were almost met. As a result of the inspection the agency has received seven requirements. The acting manager said the home had not received a Pre Inspection Questionnaire and no comment cards were received from service users and/or their relatives, friends or representatives. The evidence seen and comments received indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. The inspector would like to thank the acting manager, staff team and service users for their help and cooperation during the inspection. What the service does well: The home is a nice and comfortable place to live. People who live in the home have a good care plan that tells the staff how to care for the people using the service. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 6 Meals are tasty and there is a choice of food. People who live in the home are able to take part in a wide range of leisure activities. Staff make sure the medicines for people who live in the home are safely looked after. Staff make sure that people living in the home stay healthy and can visit the Drs when they need to. There is a caring and kind staff team who make sure people are looked after in a way that they wish. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? The home now keep a record of all food served to the people who live in the home. The home is always being improved and repairs are fixed quickly. The staff have made sure that there is still good care for the people living in the home. What they could do better: This inspection at the home has shown 7 things need to be done to make it okay. Staff must get up to date training about what to do if they see of hear about abuse at the home. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 8 The home must keep copies of all the important information and photographs of all staff. The Registered Provider is required to ensure that all care staff receive up to date training in all core subjects. The home must support the people who live in the home, and their friends and family, to make their views known. Fire Risk Assessment The home must update the Fire Risk Assessment so the people who live in the home are safe if there is a fire. There must be Risk Assessments for the home so staff and the people who live there are safe. Fire Staff must get up to date training about what to do if there is a fire in the home. DS0000013063.V326140.R01.S.doc Version 5.2 Page 9 1 Bartlett Close 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. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 10 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 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 11 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are thoroughly assessed prior to admission ensuring that staff are prepared for admission and have a clear understanding of the service users requirements. EVIDENCE: The four service users living at Bartlett Close have lived there for a number of years and there have been no new admissions to the home since 1999. There were no new needs assessments available to look at. The inspector looked at the admissions policy and the initial assessment tool. The assessment tool is called “Moving into Macintyre Care” and is comprehensive and detailed. Pictures are included alongside written information to enable the potential service users to understand the process. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. Clear and consistent care planning systems are in place that provides staff with adequate information they need to satisfactorily meet service users needs. Service users make decisions about their lives, with assistance and communication support, that allows them to influence their lifestyle and how the home is run. Risk assessments are in place that outline individual vulnerabilities and which contain control measures that enable service users to live their lives as independently as possible. EVIDENCE: Each service user has a personal file and care plans are kept within these. Preferred terms of address are included in service users plans. The inspector examined all care plans for the service uses living at the home. These are informative and comprehensive, covering a wide range of needs. Information included in these includes a pen picture, health information records, information regarding family/friends, medical information, daily routines and likes and dislikes, communication guidelines for each individual 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 13 and detailed guidelines to assist staff to support service users with particular behaviours. There is evidence that the care plans are working documents and that changes to care plans are made when the changing needs of service users warrant it. The inspector was told that service users families are involved in the careplanning process if the service user wishes them to be. The home operates a key worker system. The home attempts to involve the service users with key decisions about their lives and provide assistance as needed. However, communication difficulties with service users can make this a complex process. The home has recently undertaken a communications project to help improve communications with service users. Communication aids have been purchased and are being implemented with individuals to enhance a better understanding. Guidelines regarding missing persons and a range of individual risk assessments are in place. Examples seen include assessments for swimming, falls, using transport, use of stairs and community access. These are dated and signed and there is evidence of regular review. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. Service users can take part in age, peer and culturally appropriate activities that support and enrich service users social and educational opportunities. Service users are presented with ample opportunities for social inclusion and benefit from good staff support to do so. Staff support service users in maintaining family links and friendships inside and outside the home. Service users rights are respected and the daily routines of the home promote individual choice, providing service users with the ability to be as independent as their needs allow. The dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 15 EVIDENCE: Each service user has a daily activity plan based on his or her wishes and needs, and they are all encouraged to practice skills for daily living. Service users learning disabilities are profound and at the time of the inspection there were no individuals undertaking occupational training. Service users take part in day care activities and also have a day off in the week to undertake personal activities with the homes staff, such as personal shopping. The day care centre that was attended by service users previously has closed and the home are now funded for extra hours to provide day care activities in house. There is evidence in personal files that service users attend local amenities such as the cinema, shops, bowling, public transport, local pubs and restaurants. Service users do not vote, but are on the electoral role. Families and friends are welcomed into the home and are involved in daily routines and activities. Service users can choose whom they see and can see visitors in their own rooms, in private, if they wish. There are no restrictions about family and friends visiting. Staff knocking on bedroom, toilet and bathroom doors maintains the privacy of individuals. knocking on bedroom, toilet and bathroom doors maintains the privacy of individuals. Staff open mail with the service users, as they are unable to do so themselves and the mail is read to them. Preferred term of address are used for service users and this is recorded in the care plans. Care staff seen interacting with service users do so with respect and in a manner that is appropriate to the individual. Service users are offered a choice of suitable menus. This takes the form of staff knowing what the likes and dislikes of service users are and pictures and photographs are used to assist service users to make a choice/decision. An alternative meal can be offered if the service user does not like the day’s menu. The home offers drinks and snacks throughout the day in accordance with needs of the service users. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 16 Following the previous inspection a requirement was issued that records are kept of all meals served to residents. It is pleasing to see that this has been complied with. Individuals can take their meals in their rooms if they wish to. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are outlined within their individual plans, ensuring that the manner in which they are supported and cared for by staff is appropriate and promotes their preferences. The physical, emotional and health care needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The systems for the administration of medication are well managed, protecting service users and ensuring their medication needs are met. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 18 EVIDENCE: Information regarding personal care is recorded in the service users care plans. Service users are dependent on staff for most of their needs and staff use various communication methods to determine when service users would like to go to bed, bath, have their meals and take part in other activities. This is recorded in individual care plans. This extends to supporting service users to choose clothes, hairstyles, make up and general appearance. The home operates a link worker system. The care plans set out in detail the service users preferred routines, likes and dislikes and partnerships with families, friends and relevant professionals outside of the home. Following the previous inspection that was undertaken on the 27th July 2006 it was identified that listening devices are required in service users bedrooms for monitoring the occurrence of seizures. It was recommended that this be well documented in a restriction of liberty care plan within the main care plan and this be reviewed six monthly with a relative and/or a professional outside the home. It was also recommended that formal, written guidance be made available to ensure all staff are aware of the correct usage of such devices. There is no evidence that this has been completed and it is strongly recommended that this be completed. There are detailed records of health screening for each individual. Service users are supported and facilitated to manage their own healthcare where practicable. Service users visit their G.P. on a needs only basis. Chiropody services visit the home on a six weekly basis. There is evidence in care plans that eye screening is undertaken on a six monthly basis. Dental services are accessed six monthly at a local dentist. Additional support is accessed through the Learning Disabilities Community Team, where service users can access physiotherapists, occupational therapists, speech therapists and other specialist service they may require. Visits to the home from healthcare professionals take place in the service users bedrooms. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 19 Staff provide support to service users needing to attend outpatient and other appointments. The home operates a link worker system. The care plans set out in detail the service users preferred routines, likes and dislikes and partnerships with families, friends and relevant professionals outside of the unit. The nutritional needs of service users are identified and their weight is monitored on a regular basis. However there is one service user who does not like to be weighed and will often refuse. It is strongly recommended that that this is covered with a risk assessment. None of the service users in the home are able to self-administer their own medication. There is evidence in staff training files to show that staff have undertaken medication training via the supplying pharmacist. Records show all medication received, administered and leaving the home, or disposed of. It was pleasing to note that there are no omissions. No controlled drugs are in use. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. The home has effective complaints procedures to ensure that service users or their representatives are listened to. Policies and procedures to protect service users from abuse are in place, including financial protection. However, training records examined demonstrate that several staff have not received up to date POVA training which could put service users at risk. EVIDENCE: The complaints procedure is displayed on the notice board and is available in Rebus for service users benefit. The home’s complaints procedure now includes the contact details of CSCI. Following the previous inspection it was identified that 20 of complaints were not responded to within 28 days. A requirement was issued for complainants to be notified of any action to be taken, if any, within 28 days. The acting manager said that the home has not received any complaints since the previous inspection so this was difficult to assess. However the acting manager assured the inspector stated that this would be complied with if any complaints are received. The home use the Oxfordshire’s Multi-Agency codes of practice for the protection of vulnerable adults. In addition MacIntyre Care provides a policy called “Protecting Vulnerable Adults from Abuse” This contains guidelines about the responsibilities of the staff, types and signs of abuse and what to do if you suspect abuse. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 21 There is a public disclosure policy dated Sept 2003. Following the previous inspection a requirement was issued for the home to notify the Commission for Social Care Inspection of any allegations made against any member of staff. The acting manager said that she would do this if any allegations were made against staff. Following an examination of training records it was evident that staff are not up to date with POVA training. The organisations policies regarding service users money and financial affairs ensure service users access to their money, valuables and safe storage is safe guarded. There is a gift procedure that provides staff with guidelines about receiving personal gifts from service users. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 22 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, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good, providing service users with an attractive and homely place to live. The overall quality of the furnishings and fittings is good ensuring the safety and comfort of service users. Standards of cleanliness in the home is good, meaning that service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. EVIDENCE: The home was purpose-built 11 years ago. It was planned with the assistance of one of the current residents, and continues to meet the needs of residents with a physical disability. A new kitchen is planned for 2007. There are plans to convert the laundry room and to refurbish the kitchen in 2007. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 23 The house is well maintained and nicely decorated. All bedrooms in the home are personalised with service users own belongings. Each room is decorated individually to suit the tastes and choices of service users. The kitchen is accessible to service users if they wish to assist with meal preparation. The home provides adequate toilets, shower and bathing areas. The laundry facilities for the home are sited so that soiled washing does not come into contact with the kitchen. Hand washing facilities are sited in the laundry. The carpet at the top of the stairs is very stained and it is strongly recommended that they receive a thorough clean or is replaced. The floors in the laundry are washable and the walls easily cleanable. Instructions were observed in the laundry regarding the washing of foul linen. Policies and procedures were observed by the inspector for the control of infection, which includes the safe handling and disposal of clinical waste. A tour of the home shows that cleanliness in the bedrooms and the communal areas is maintained. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 24 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 and 35. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Not all necessary training has been completed or is updated to ensure all staff are competent and qualified to do their job, ensuring that service users are cared for by skilled staff at all times. There are recruitment procedures in place to ensure service users are protected from harm. However, files need to be held in the home and must contain appropriate evidence to demonstrate that all recruitments checks have been undertaken. EVIDENCE: Some progress is being made with NVQ training. At the time of the visit the manager has NVQ level 3 training and one support worker is due to complete NVQ level 3 training shortly. One support worker has achieved NVQ level 2 training. The required ratio of staff trained to NVQ level 2 has not been achieved and will be a requirement of the report. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 25 Documentation for staff recruitment is now kept at a central office. However, the home must maintain a record of all persons employed at the home as detailed in Schedule 4 of the Care Homes Regulations for Younger Adults. A random selection of staff files/documentation were looked at during the visit. Overall these found to be of a good standard. However, one file did not contain copies of one reference, although this was available at the central office, and there was a lack of proof of identity, i.e. copies of birth certificates or/ and passports. These were being held at the central office. The registered provider must ensure that this information is maintained in the home and is a requirement of the report. There is an induction programme in place to ensure that new staff members are familiarised with the organisation and their roles and responsibilities and provides the staff member with a personal development portfolio. Staff then complete CWPLD training. Records show that staff are not up to date with mandatory training and the acting manager has already identified this as an area for further development. Following the previous inspection a requirement was issued that staff have received the identified training as described in the report. This has not been complied with and will remain a requirement of the report. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 26 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 adequate. This judgement has been made using available evidence including a visit to this service. There is an acting manager in post and she appears to have a good understanding of the areas in which the unit need to improve. There is no evidence that the home regularly reviews aspects of its performance through a programme of self-review and consultations, which include seeking the views of service users, staff and relatives. There are systems within the home that are used to ensure that service users health, safety and welfare are protected and promoted. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 27 EVIDENCE: The acting manager has been in her present role since September 2006. She is due to attend interview the following day. She has NVQ level 3 training and has worked at the home as a support worker for one year and a senior carer for two years. There is little administration for the home and at the time of the inspection there was no computer or fax machine. This results in very confidential information being sent through the general post. It is strongly recommended that the home is provided with extra administration support or appropriate equipment to carry out administration within the home. The home has a complaints procedure in place and a whistle blowing policy, which enable staff and service users to voice concerns and affect the way in which the service is delivered. Macintyre Care has an equal opportunities policy in place and this is accessible to all staff. There home undertakes various methods of regularly reviewing aspects of its performance. For example monthly reviews are undertaken of staff sickness, the use of agency staff, accidents and incidents. At the previous inspection a requirement was issued for the organisation to supply a copy of the last Annual Quality Review to the CSCI. There is no evidence available in the home to demonstrate that this has been complied with and will remain a requirement of this report. There are Regulation 26 reports available for inspection. Fire alarm testing is undertaken weekly and fire drills are carried out with the full involvement of the service users. Documents held at the home show that the most recent visit by the fire authority appears to have been carried out on 02/03/04 and the acting manager was asked to check that this was the case. The fire based risk assessment needs to be reviewed and this will be a requirement of the report. Fire training for some care staff needs to be updated and the home must ensure that all care staff receive basic fire awareness training on their initial induction and then annually. This must be recorded. This will be a requirement of the report. The home has an infection control policy that is detailed and comprehensive. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 28 There has been no generic risk assessments completed for the home. The acting manager has already identified his as an area that needs further development. However, she has not received guidance or training to do this and is due to attend interview the following day for the post of manager. It is unsure at this time whether she will be in the position to complete these. Therefore it will be the registered provider who will be required to complete these and is a requirement of the report. Service certificates for gas appliances are dated 02/06/06 and PAT testing was last undertaken on 19/06/06. Hoists were last serviced on 07/06/06. There is evidence of water temperature recording and accident and incident reports. There is a water chlorination certificate dated 06/01/06. Hazardous substances are stored appropriately and COSHH risk assessments are up to date. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 30 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 YA23 Regulation 13 Requirement The Registered Provider is required to ensure that all care staff receive up to date POVA training. The Registered Provider is required to ensure that the home maintains a record of all persons employed at the home as detailed in Schedule 2 and Schedule 4 of the Care Homes Regulations for Younger Adults. The Registered Provider is required to ensure that all care staff receive up to date training in all core subjects. The Registered Provider is required to ensure that an effective quality assurance and quality monitoring system, based on seeking the views of service users and their relative/representative, are implemented. The Registered Provider is required to ensure that the Fire Based Risk Assessment is updated. The Registered Provider is required to ensure that Generic Risk Assessments are completed DS0000013063.V326140.R01.S.doc Timescale for action 30/04/07 2 YA34 17 Schedule 2 and 4 30/01/07 3 YA35 18 30/05/07 4 YA39 12 30/06/07 5 YA42 23 28/02/07 6 YA42 12 30/03/07 1 Bartlett Close Version 5.2 Page 31 by persons competent to do so. 7 YA42 23 The Registered Provider is required to ensure that all staff receive up to date fire safety training. 30/05/07 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 Refer to Standard YA8 YA24 YA37 Good Practice Recommendations It is strongly recommended that a risk assessment is in place for any individual who refuses to be weighed on a regular basis. It is strongly recommended that the carpet on the upper landing is either cleaned or replaced. It is strongly recommended that the home receive extra administration support or are provided with the appropriate equipment to carry out administration within the home. 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 1 Bartlett Close DS0000013063.V326140.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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