Inspection on 04/09/06 for Bendalls Farm

This inspection was carried out on 4th September 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME ADULTS 18-65 Bendalls Farm Green Ore Nr Wells Somerset BA5 3EX Lead Inspector David Kidner Key Unannounced Inspection 4th September 2006 09:30 Bendalls Farm DS0000064605.V310503.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 Bendalls Farm DS0000064605.V310503.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. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bendalls Farm Address Green Ore Nr Wells Somerset BA5 3EX 01761 241014 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) Mr Neil Bradbury t/a Bradbury House Organisation Mr Lee M. Janes Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate six person under the registration categories MD & LD (because of their mental health needs as well as their learning disability). N/A Date of last inspection Brief Description of the Service: Bendalls Farm is a large detached property situated in approximately 200 acres of farmland. It is located 4 miles from the market town Wells. The home is in easy access of main roads and local services. The Registered Manager is Mr Lee Janes. Bradbury House Organisation owns the home. The home was registered with the Commission for Social Care Inspection (CSCI) on the 17/05/06. The home is registered to accommodate six services users. Currently there are five service users accommodated at the home. The accommodation is arranged over two floors. On the ground floor there is a lounge, a games room with a kitchenette, kitchen, utility area, toilet and staff office space. On the first floor there are six bedrooms with full en-suite facilities, all with shower cubicles however, there is also a communal bathroom for service users if they choose to have a bath. Staff sleep-in facilities are also located on the first floor. The home does not have a lift therefore; it would be unsuitable for service users with high mobility needs, however a bedroom with full en-suite facilities can be provided if needed. This bedroom meets the national minimum standards. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection conducted by the Commission for Social Care Inspection. This inspection was a Key Unannounced Inspection and was conducted by one Inspector. The inspection lasted one day (8hrs). The Inspector met all the service users and a number of the care team. The Registered Manager was present for the inspection. As part of the inspection process the inspector viewed records in relation to care and support plans, health and safety, medicines, risk management, the management of behaviours and physical intervention, staff recruitment and viewed all areas of the home. The Inspector spoke to three service users in private and spoke to a total of four care staff. The Inspector would like to thank the service users for making the Inspector welcome in their home and for their contribution in the inspection process. The Registered Manager and care team were very welcoming and presented themselves in a professional manner. As part of the inspection process the Inspector sent comment cards to four relatives. Two were returned. The Inspector sent comment cards and spoke to all Care Managers/ Assessment and Reviewing Officer. On the whole the comments were extremely positive in relation to the care and support provided at Bendalls Farm. Positive comments were also received in relation to the Registered Manager and the care team. Some comments received from service users include: ‘I am very happy here’ ‘I like the house and my bedroom’ ‘I have choices in food and clothes’ ‘I like the grounds and the animals’ ‘I have friends here’ ‘Staff don’t invade my privacy’ As a result of this inspection the home has two requirements and three recommendations. What the service does well: Bendalls Farm provides a very comfortable environment for service users who wish to live in a rural setting and have a keen interest in farm work/activities. The home is furnished and maintained to a high standard. There is ample communal space. All bedrooms have en-suite facilities and reflect individual preferences and lifestyles. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 6 Care and support plans reflect individual needs and contained appropriate documentation. The Registered Manager has conducted detailed risk assessments and where restrictions are imposed this is well recorded. The home promotes choice, service user involvement and empowerment. Service users confirmed that they access a variety of leisure and recreational facilities. The home has clear management policies and procedures in relation to the protection of vulnerable adults. There are detailed policies on the use of physical intervention and the management of challenging behaviour. All staff have received NAPPI training. The home is well run and the Registered Manager shows leadership and direction. Staff receive support and regular supervision. 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. Bendalls Farm DS0000064605.V310503.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 Bendalls Farm DS0000064605.V310503.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 124 The outcome group is Good The home has a detailed Statement of Purpose and Service user Guide. The service user guide is presented in an accessible format. The home has a detailed Pre-Admission assessment process. EVIDENCE: The home has a detailed Statement of Purpose and has developed a Service User Guide that is produced in an accessible format for service users. The Fee varies depending on the individual service user’s assessed needs. The home has an Assessment and Admission Policy. Each potential service user is assessed on a needs led basis. The Inspector met all service users and spoke to four of the five service users. Four service users have lived at the home since May 2006 and were able to visit the home prior to moving in. The Inspector spoke to the service user who had moved to the home three days before the inspection. They confirmed that they had visited the home before moving in and so far were very happy with living at Bendalls Farm. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 9 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 9 10 The quality outcome group is Good The home has detailed care plans that reflect service user’s current needs. There are also detailed risk assessments that support and restrictions imposed on service users. Service users are offered as much choice as possible and are encouraged to make decisions. Service users confidential information is kept secure. EVIDENCE: The Inspector viewed the care and support plans for three service users. One care plan is in the process of being developed. The other two care plans were presented in an accessible format and contained detailed information relating to the individual care and support that is needed. The Inspector was able to establish the current needs and identify the action that the home is taking to address such matters. The care plans clearly set out any restrictions on choice and freedom and focuses on structured environments and positive behaviour. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 10 Each service user has an allocated key worker. The key worker completes a monthly summary of the care that has been provided and identifies areas of concern and positive outcomes. The home also completes day-to-day diaries for each service user. The service users that the Inspector spoke to were aware of their care plans and were able to make comments about some of their content. It was very evident at the time of the inspection that service users are offered choices on a day-to-day basis. The Inspector witnessed service users being offered choice and being encouraged in decision-making. Service users stated that they have choices in many things such as food, drinks, time to get up and go to bed and the clothes that they wear. Any restrictions and limitation on choice or human rights are identified in the care plan. However, service users were able to inform the Inspector of restrictions that are imposed and the reasons why. All service users are able to voice their opinion and currently do not need Advocacy services. Service users who manage their finances are supported where needed. The home has completed accessible and detailed risk assessments in relation to any restrictions and limitations imposed. These are reviewed on a regular basis. The Inspector discussed with the Registered Manager if the frequency of some risk assessments needed to be reviewed. The Registered Manager acknowledged this and agreed to review the frequency dates. The home has a policy relating to unexplained absences. Service users and their families have access to the home’s policies and procedures on confidentiality. Service users records appear accurate and are kept secure and confidential. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 11 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 15 16 17 The quality outcome group is Good. The service users have access to facilities to develop and nurture skills and provide meaningful occupation. Service users are supported to access a variety of social and leisure activities. The home provides service users with very good facilities to promote hobbies and recreation. Contact with families is supported. The home promotes service user involvement, choice and decision-making. Health eating is promoted. EVIDENCE: Bradbury House Organisation also operates a day service facility within the 200 acres of land that the home is located. It offers people opportunities to develop skills and experience in horticulture, agriculture and animal care. This facility is Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 12 also an accredited educational outreach centre for Filton College. All service users attend the day service facility. Some of the service users who live at Bendalls Farm also access work placement at the facility for which they receive therapeutic earnings. All service users that the Inspector spoke to stated that they loved working with the animals and enjoyed going to the day centre facility. Service users are able to access a variety of local facilities and resources and pursue their own hobbies and interests. Due to the needs of some service users visits and trips out are always supported by care staff. Where appropriate detailed risk assessments are completed. Service user confirmed that they enjoy going for walk on the farm, listening to music in their rooms, watching television, DVD and computer games. The home also has a large games room that has a pool table, dartboard, tabletop football and a Hi-Fi. This appears to be a very popular resource. There is also a small kitchenette with a fridge and tea and coffee making facilities. Service users maintain regular contacts with their family and friends. The home keeps records of contacts and visits. The service users that the Inspector spoke to confirmed that they have regular contact with their families and friends as they so wish. The service users are encouraged to partake in all aspects of the running of the home. All service users are responsible for cleaning their bedrooms and ensuite facilities and are involved as mush as possible in the laundry of their clothes and other household responsibilities. Service users have a key to their bedroom. The Inspector observed staff interacting with service users in a mature, relaxed and professional manner. One service user has a dog as a pet and takes it for walks around the farmland. All service users agreed to this. The pet does not live in the main part of the home. Smoking is not allowed in the home. If service users or staff wish to smoke an allocated are has been provided outside of the home. The home obtains most of its organic vegetables from the farm. Healthy eating is promoted. However, the home does not have set menus as service users choose on a daily basis what the preferred meal option is. Alternatives are provided. Each service user takes it in turn to cook the main meal of the day. All meals provided are recorded daily. At the time of the inspection the Inspector noted that the lunch and evening meal appeared nourishing and well presented. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 13 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): 18 19 20 The quality outcome group is Adequate. Care staff are aware of service user’s needs in relation to personal care and support. Service users have access to a variety of healthcare professionals. The home needs to improve in some areas of the management of medicines. EVIDENCE: The service users that the Inspector spoke to confirmed that there are no set time for getting up and going to bed. Service users are independent when it comes to support with personal care. All bedrooms have en-suite facilities therefore privacy is further promoted. Service users choose their own clothing. All service users were very well attired. All service users have access to additional specialist support services if required. The Inspector was able to view documentation in relation to visits to other healthcare professionals. The Inspector viewed the arrangements for medicines. The home has a policy for the management of medicines and designated staff are nominated to Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 14 dispense medicines. They have been assessed as competent in the management of medicines. The Inspector viewed the MAR sheets. It was noted that two staff signatures did not support three hand transcribed medicines and variable doses must be recorded. The fridge that stores the insulin must be fitted with a lock and a maximum and minimum thermometer should be purchased. The home maintains a record of the temperatures. The home maintains a medicines returns book. There are no Controlled medicines stored at the home. There is a protocol for the administration of PRN medication. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 15 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 23 The outcome group is Good. The home has clear management policies and procedures in relation to the protection of vulnerable adults. Good records are kept in relation to the use of physical intervention, behaviour management, risk assessments and the management of service user’s finances. EVIDENCE: The home has a Complaints Policy and Procedure. There have been no recorded complaints at the home. The service users that the Inspector spoke to stated that they would know what to do if they were unhappy with the care and support that they were receiving and knew how to make a complaint. The home displays the complaints procedure in a prominent place. The home has policies for the protection of vulnerable adults including policies for adult protection and the management of service user’s finances. Care staff that the Inspector spoke to was aware of the home’s Whistleblowing Policy. All staff have received training in Abuse Awareness and have undertaken NonAbusive Psychological and Physical Intervention Training (NAPPI) and receive refresher training annually. The home keeps detailed records in relation to the use of physical intervention. The Inspector was able to view detailed care plans, behaviour management guidelines, risk analysis and risk assessments in relation to the management of Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 16 behaviours and the use of physical intervention. The Inspector spoke to one service user who has experienced the use of physical intervention. They commented that when it has been used the staff knew what they were doing and they did it to keep me safe. The Inspector discussed the arrangements for the management of service user’s finances with the Registered Manager. Service users have individual bank or building society accounts. One service user fully manages their finances, a parent is another appointee and the Organisation is the appointee the two other service users. Detailed records are kept where the home supports service users to manage their personal allowance only. Where able service users countersign the receipt of personal spending money and manage the money themselves. The Registered Manager audits the financial records on a monthly basis. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 17 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 25 26 27 28 29 30 The quality outcome is Good. Bendalls Farm provides a very comfortable environment for service users who wish to live in a rural setting and have a keen interest in farm work/activities. The home is decorated and furnished to a high standard and provides very good communal facilities. All bedrooms have full en-suite facilities. They also reflected individual lifestyles and needs. On the day of the inspection the home was clean and hygienic. EVIDENCE: Bendalls Farm provides a very comfortable and homely environment. The furnishings and fittings are of a high standard and quality. It is located in approximately 200 acres of farm land but is in easy access of the market town of Wells and is on a bus route with easy access to local facilities. All bedrooms are single occupancy and are located on the first floor. They are fitted with appropriate locks. It was noted that the service users have keys to their bedroom. The Inspector viewed all bedrooms. They reflected individual Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 18 life styles and preferences. Some service user have personalised their rooms to their liking and contained a variety of personal possessions and appeared very homely and appropriate to the age group of the service users. Where appropriate SKT TV is installed in bedroom areas as well as in the lounge. All bedrooms meet or exceed the national minimum standards. All bedrooms have full en-suite facilities that are fitted with shower cubicles. Therefore, privacy and dignity is further promoted. Service users stated that staff knock on the bedroom doors before being invited to enter. There is also a family style bathroom if a service user wishes to take a bath. The bath has an automatic fill that has a time delay and other safety measures fitted. There are adequate communal toilet facilities with appropriate hand washing facilities. The home has ample communal space. There is a large lounge area that has quality furnishings and fittings and has access to a patio area to the front with extensive views across the farm. There is a very large games room that has a pool table, table football, darts board, Hi-FI and a small kitchenette where service users can make a drink. This is a very popular facility. There is also a smaller room that houses two Playstations and the home supports service users to access appropriate games. These are excellent facilities and well liked by the service users. The laundry and kitchen facilities are domestic in style. Staff have appropriate sleep-in facilities. The sleep-in room is located on the first floor. Waking night staff are also present. The home currently does not need to provide any specialist aids and adaptations. On the day of the inspection the home was clean and hygienic. Appropriate hand washing facilities are provided in communal areas. The laundry area was clean and well managed. Staff support service users to keep their bedroom clean and tidy and are involved in the cleaning of the home. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 19 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 35 36 The quality outcome group is Good. Staff demonstrated their awareness in the support required to meet service user’s individual needs. Although the care team do not have an NVQ qualification the service is proactive in addressing this matter and has developed an action plan. Staff are supported well and receive regular formal supervision. EVIDENCE: The home opened in May 2006. The current care team came from existing care teams that were employed in other various homes within the Bradbury House Organisation. The Inspector spoke to a number of staff at the time of the inspection. Staff were able to demonstrate their awareness and understanding of the service users needs. All staff have received training in Abuse Awareness and have undertaken NAPPI Training and receive refresher training annually. Following discussions with the care team and the Registered Manager it is recommended that the care team receive training in matters relating to Mental Health. There is currently seven care staff employed at the home. The staff team are undertaking LDAF (Learning Disability Awards framework) training at induction and foundation level. The home currently employs seven care staff; no staff Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 20 members have an NVQ qualification. The home has had difficulty in accessing external assessors in their locality so the service has decided to address this matter internally. Senior Managers are undertaking appropriate NVQ qualifications, the Registered Managers Award and A1 Assessors Award as needed. This demonstrates the services commitment in providing a wellqualified workforce. The service has developed an action plan to promote NVQ qualification. It is expected that a programme for NVQ Level2 in Care will commence towards the end of December 2006. The home has not employed any new staff. As previously stated, the Bradbury House Organisation previously employed all care staff. All staff have Enhanced CRB Disclosures. The Registered Manager is aware of the need to ensure that the recruitment files of any newly appointed staff contain all the required documentation as listed in Schedule 2 of The Care Homes Regulations 2001. Therefore, core standard number 34 could not be assessed at this inspection. All staff have an individual staff training and development plan. Bradbury Homes Organisation has a Training and Development Manager. All staff receive regular supervision with records kept. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 21 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 The quality outcome group is Good. The home is well run and the Registered Manager shows leadership and direction. The home promotes health and safety, however some areas need addressing. EVIDENCE: The Registered Manager is Mr Lee Janes. Mr Janes has been working with people with learning g difficulties and mental health needs in a variety of settings for approximately twelve years. He has a NVQ Level4 in Care, NEBS Management and is due to complete the Registered Managers Award this autumn. He has also enrolled to undertake the A1 Assessors Award. Mr Janes has attended appropriate training and undertakes refresher training when needed. Staff that the Inspector spoke to spoke very highly of Mr Jane’s management style. Staff stated that he is very fair and supportive manager. He shows clear direction and leadership and has an open door policy. He is a good role model Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 22 and has a good rapport with the service users. Staff confirmed that Team Meeting are held regularly and are very beneficial. Minutes are kept of all meetings held. The Inspector viewed the minutes to the last meeting. The service users that the Inspector spoke to stated that they have house meetings and that they found them worthwhile and that they could raise any issues. Minutes are kept of service users meetings. The Inspector viewed the minutes to the last service users meeting held in August 2006. The minutes demonstrated that service users views and ideas had been had been sought. It is expected that these meetings will be held monthly. On the day of the inspection the Inspector found Mr Janes to be very open and professional and gave an impression of being a very competent manager. The Inspector viewed a number of documentation in relation to health and safety. Fire Safety: The home has conducted a Fire Risk Assessment dated 11/08/06. The fire alarm system and emergency lighting system were installed on the 08/05/06. Fire extinguishers were installed in May 06. Monthly records are kept of visual checks of the fire equipment. The emergency lighting is tested monthly and was last tested on the 25/08/06. Weekly checks are conducted on the fire system the last check was conducted on 29/08/06. The home conducts monthly fire drills. The Registered Manager will be including service users in fire drills in the future. All staff have received fire training. The Registered manager stated that regular fire training would be held. The Inspector suggested that the home obtains the HSE Fire Safety: An employers Guide for reference. Hot Water/ Legionnella: The Registered Manager stated that all hot water outlets have thermostatic valves fitted to ensure that the temperature does not exceed the recommended levels. On the day of the inspection the hot water from the bath exceeded the recommended temperature. The Inspector recommends that the home keep records of regular testing of the hot water from the showers, washbasins and bath to ensure that they do not exceed the recommended temperature of 44 degrees centigrade for baths and 43 degrees centigrade for showers. The home’s compliance with Legionella is dated May 2006. Electrical Hardwiring Certificate: This is dated 28/04/06 Oil Firing installation report: The home has oil-fired central heating and a completion report for the installation of this is dated 04/05/06. Accidents: The Registered Manager stated that all records are kept of accidents / incidents. These are audited on a regular basis. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 23 COSHH: The home has a policy in relation to this. All products are stored securely. Fridge/Freezer: The home keeps daily records of fridge and freezers. Risk Assessments: The home has a detailed risk management policy. The Inspector viewed a number of individual and environmental risk assessments. However, it was noted that first floor windows have not been fitted with restrictors and freestanding wardrobes had not been secured. The Registered Manager must conduct detailed individual service user risk assessments to identify if windows need restricting and wardrobes need securing. This will further promote health and safety. First Aid: Staff receive training in first aid. Records viewed confirmed that three care staff needed this training. The Registered Manager is aware of this and it has been noted. The Inspector also suggested that the home obtains the HSE Health and Safety in Care Homes for reference. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 3 X X X 2 X Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 25 N/A 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 YA20 Regulation 13 (2) Requirement Timescale for action 09/10/06 2. YA42 13 (4) The Registered Manager must ensure that a lock is fitted to the fridge used for the storage of insulin. Also, variable doses must be recorded on MAR sheets to confirm the amount administered. The Registered Manager must 09/10/06 conduct individual detailed risk assessments in relation to the fitting of restrictors on first floor windows and securing freestanding bedroom wardrobes. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations The Registered Manager should ensure that two staff signatures support hand transcribed medicines. A minimum and maximum thermometer should be purchased. The Registered Manager should consider providing the care DS0000064605.V310503.R01.S.doc Version 5.2 Page 26 2. YA32 Bendalls Farm 3. YA42 team with training relating to Mental Health matters. The Registered Manager should keep records of regular checks of the hot water from the showers, washbasins and bath to ensure that they do not exceed the recommended temperature of 44 degrees centigrade for baths and 43 degrees centigrade for showers. Bendalls Farm DS0000064605.V310503.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Bendalls Farm DS0000064605.V310503.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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