Inspection on 16/01/07 for Brambletye

This inspection was carried out on 16th January 2007.

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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brambletye 27/09/07

Brambletye 22/11/05

Brambletye 28/06/05

Brambletye 11/10/04

Brambletye 02/06/04

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 Brambletye New Mill Road Finchampstead Berkshire RG40 4BT Lead Inspector Mrs Rhian Williams-Flew Unannounced Inspection 16th January 2007 11:00 DS0000051756.V325863.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 DS0000051756.V325863.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. DS0000051756.V325863.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brambletye Address New Mill Road Finchampstead Berkshire RG40 4BT 0118 973 4539 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) www.new-support.org.uk New Support Options Limited Post Vacant Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places DS0000051756.V325863.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of service users to be accommodated at any one time should not exceed 5 (five) 22nd November 2005 Date of last inspection Brief Description of the Service: The house is owned by the Maidenhead/Windsor Housing Association, and the care is provided by New Support Options. The home is registered to provide accommodation for up to five service users who have learning disabilities. Presently, only four service users are accommodated. The home is in a very rural location, not on a public transport route. It is situated approximately five miles from Wokingham Town Centre, with Bracknell and Reading also within a short distance. The home has its own adapted vehicle and service users are able to use taxis if necessary. The home has all the accommodation on the ground floor. The communal accommodation is spacious. There is a large garden that is accessible to all service users. There are four bedrooms, one room has an en-suite shower room and one room has a lounge area and en-suite bathroom. There is a communal bathroom, which has a specialist bath and hoisting equipment. The home is equipped with aids and adaptations to assist in the care of the service users. The fees charged by the service are £1617.61 a week. This figure was verified with the provider in January 2007. There are additional charges for toiletries; hairdressing; clothing and other personal effects the service users might wish to have. The area manager has confirmed that the Commission for Social Care Inspection reports are available in the home should any service users; their carer or other persons wish to view them. The homes own Statement of Purpose and Service User Guide are yet to be published. DS0000051756.V325863.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 of a re-opened service. The home has been a registered service for a number of years but in the middle of 2006 the previous service users moved to other facilities and the home was closed for refurbishment. The new service opened on 6 November 2006. The accumulated evidence used to inform this report includes a pre-inspection questionnaire completed by the manager (Louise Dobson); our inspection records held at the local office of CSCI; an unannounced site visit on 16 January 2007; one CSCI survey returned by a service users carers and, subsequent to the inspection a discussion with the area manager for the service. The site visit took place between 11:00 hrs and 17:30 hrs and was conducted by one Inspector. During the unannounced site visit conversations were held with four members of staff on duty; a tour of the service was made; all service users case files were case tracked and some records concerning the management of the service were reviewed. The manager was on leave but a senior support worker was present during the inspection. The Inspector was unable to seek the views of the service users as they are unable to communicate with language however, she did observe the care offered to the service users throughout the visit. Two relatives who were visiting the home were also spoken with to seek their views. What the service does well: All of the service users had their care needs thoroughly assessed prior to their admission to the home. Their carers were included in these assessments to ensure their views were taken account of. The environment of the home was adapted to meet the needs of the service users and sufficient members of staff have been employed to provide the care. Members of staff were observed to be providing compassionate care that was inclusive of the service users. Some of the members of staff have previously worked with some the service users therefore their knowledge of their likes and dislikes is good. Service users have lifestyles and activities that they enjoy. They each pursue different activities throughout the day. They all use the local community facilities. The families and carers of all the service users visit or the service users visit them regularly. Carers who were visiting during the site visit were effusive in their praise of how included they feel when they visit the home. The nutritional needs of the service users are well monitored and professional advice is sought to ensure they receive a balanced diet. Members of staff also ensure that appropriate healthcare advice is sought when the service users require it. Medication procedures are clear and members of staff had a good knowledge of the process. DS0000051756.V325863.R01.S.doc Version 5.2 Page 6 The provider has established policies and procedures with regard to complaints and safeguarding vulnerable adults. There have been no complaints to the home or the CSCI since the service re-opened. With the exception of the choice of communal bathing facilities in the home the service provides a spacious, comfortable and homely place for service users to live. All areas of the home are accessible for people who use a wheelchair. The manager ensures that the home is regularly maintained and is a safe place for service users and member of staff to live and work. There are sufficient staff allocated to the home and 75 of the members of care staff have achieved their NVQ 2 or above. The manager is qualified and experienced to run the home. She has yet to apply to become the Registered Manager as required by the Care Standards Act 2000. 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. DS0000051756.V325863.R01.S.doc Version 5.2 Page 7 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. DS0000051756.V325863.R01.S.doc Version 5.2 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 DS0000051756.V325863.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. The service users and their carers have been fully involved in the choice and, provisions within the home. All service users had their care needs thoroughly assessed through the care management procedures. The provision of the Statement of Purpose and Service User Guide to the service users and their carers would complete the information they require. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service re-opened on 6 November 2006. The manager of the service confirmed in a pre-inspection questionnaire that the Statement of Purpose and Service User Guide were being rewritten. During the site visit the manager was on leave and it was not possible to evidence the documents referred to above. The area manager for the service has confirmed that work on the new documents has been commenced. It is therefore recommended that on her return from annual leave the manager complete the two documents and publish them. All existing service users and their carers should receive copies of them and copies should be forwarded to the Commission for Social Care Inspection. DS0000051756.V325863.R01.S.doc Version 5.2 Page 10 There is recent guidance on the Commission for Social Care Inspection website regarding the change in regulations about the publishing of fees and costs that a service user can expect to pay in the Statement of Purpose and Service User Guide. The four service users who live in this home moved in on the above date. Two service users had previously lived for many years in another care home; one service user had lived in another home for a number of years and the other service user had previously lived with carers. All service users had received a full assessment of their care needs through the care management arrangements of the local authority. These assessments could be evidenced in the persons care files. The transition for the three service users transferring from other care homes had been conducted in consultation with their carers and advocates and the service users had visited the service on many occasions to familiarise themselves with their new living environment and to meet one another. The service user who was being admitted from their home environment also had a staged introduction to the home and their carers were consulted with regards the provision of the environment the person lives within. DS0000051756.V325863.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. Service users care plans and risk assessments are not up-to-date and relevant to the home they are living within. However, the observed care practices of the staff and discussions with them clearly indicate their knowledge and understanding of the service users. This knowledge and care delivery must be captured in the service users individual care plans and risk assessments and be regularly reviewed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for all four service users were reviewed. For the three service users who have come from other homes their case files contained detailed information about their care needs and wishes however, they were not related to the service they have moved to. The care plans reflected the care needs of DS0000051756.V325863.R01.S.doc Version 5.2 Page 12 the people at their previous establishments. Whilst some of their care needs remain as previously stated members of staff did confirm that in recent times the care needs of these service users have started to change. These changes were not evident in the care plans. The care plan for the other service user was in its formative stages. Subsequent to the inspection it has been confirmed that the care plan has been developed further. In discussions with members of staff on duty (some of whom had previously looked after the service users at the other establishments) they demonstrated considerable knowledge about all the service users care needs. This is particularly relevant as none of the service users are able to communicate with language and therefore understanding their non-verbal communication is very important. The observed interactions of the staff on duty at the time of the site visit clearly demonstrated their knowledge and understanding of the service users needs and wishes. This understanding and knowledge must be captured in the written care plans to ensure that all staff are consistent in their approach and delivery of care to the service users. Also, as and when service users care needs change (as has recently occurred for all the service users) the care plans should reflect these changes. In the one CSCI survey that was returned the parents of one service user commented that their relatives daily routine was decided by his carers according to his needs. All of the service users have very limited communication skills. Decisions about their lives and lifestyles are made by people who know them best, their carers and the staff of care for them. All of the service users have carers and relatives who remain in frequent contact with them and advocate on their behalf. The home manager has indicated in the pre-inspection questionnaire that the next of kin for all the service users act as their appointees with regard to financial decisions. As with the care plans the risk assessments for the service users did not apply to their new accommodation. For the three service users who had been cared for at previous homes, their risk assessments applied to those establishments. The newly admitted service user had limited risk assessments completed. Subsequent to the inspection confirmation has been received that more detailed risk assessments have now been completed for this service user. Risk assessments must be relevant to the circumstances that the service users are receiving their care within. They must be up to date, regularly reviewed and all staff should be familiar with the risk issues. DS0000051756.V325863.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. The service users participate in activities that meet their needs. They make use of the services in their community. Their friendships and relationships with other are positively encouraged. Their nutritional needs are well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three of the service users are under the age of 60 years and one service user is, over the age of 65. None of the service users are presently able to participate in employment or continuing education and training. One service user attends a local day services facility four mornings a week. The other service users participate in activities that they find enjoyment in. These activities are usually pursued on an individual basis. DS0000051756.V325863.R01.S.doc Version 5.2 Page 14 All the service users participate in the local community, using the services such as libraries, shops, cinema, leisure centres and places of worship, pubs and restaurants. The activity schedule for each of the service users clearly indicated they have interesting and diverse activities that they enjoy participating in. All of the service users maintain links with their families that the members of staff promote and encourage. Some service users are able to visit their family members in their home. On the day of the site visit a service users parents were visiting. They were effusive in their praise of how included they feel in the care of their relative when they visit the home. The observed practice of the staff during the site visit with regard to the daily routines of the service users were observed to be very good. Members of staff were respectful and always spoke to the service users to reassure them of the activity they were about to participate in. When carrying out care tasks with the service users the members of staff always interacted with them. The service users clearly responded to this level of socialisation. Three of the service users have their nutrition and dietary needs monitored by professionals who are able to give specific dietary advice. The menus were reviewed and it was noted that a nutritious, varied and balanced diet is provided. All of the service users have specific nutritional needs; they either require soft or puréed foods. As the service prepares a significantly high proportion of the meals from fresh ingredients this ensures the service users receive meals that are well presented and are appetising. One service user receives their nutrition from a PEG feeding tube directly into their stomach. Although this person is unable to eat food they are included in the socialisation of the mealtime. It was noted that the service users who are assisted with their feeding are fed with appropriate eating aids and at a speed that suits them. Members of staff were noted to be particularly encouraging of one service user who was reluctant to share their meal with others. Through their persistence and encouragement they were able to assist this person to eat their meal in another part of the home. DS0000051756.V325863.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate. Service users personal care needs are met as the staff team are knowledgeable about the service users preferences but evidencing how this is currently achieved was not detailed in their care plans. There are also issues of privacy and dignity that need to be addressed with regard to the bathing/showering arrangements in the home. The service users healthcare needs are met and staff ensure that appropriate support is accessed for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As the service users care plans were not current to the service they are living within, it was difficult to assess from written evidence as to whether they are receiving their personal care in a way that they would prefer and required. However, in discussions with the members of staff on duty their knowledge and understanding of each service user demonstrated that they understood their needs and preferences with regards to the service users personal care needs. Some of the information from the service users previous care plans DS0000051756.V325863.R01.S.doc Version 5.2 Page 16 (from their previous establishments) did indicate their preferences with regard to getting up/going to bed, choice of clothing, bathing preferences etc. These preferences corresponded with the knowledge and understanding of the members of staff. From observations on the site visit it was clear that the members of staff knew the service users personal preferences with regard to their personal care. In discussions with members of staff the preferences for the bathing/showering arrangements of the service users were identified by the Inspector as an area where their privacy and dignity could be compromised. Subsequent to the inspection and to ensure the confidentially of all the service users this matter has been fully discussed with the area manager ( the home manager was on holiday) for the service. She agreed that the matter should be reviewed promptly. The manager should review the provision of bathing and showing facilities within the home to ensure they are sufficient to meet the needs of all the service users whilst ensuring their privacy and dignity. The advice of healthcare professionals is sought. Referrals were seen for these professionals to assess the service users needs and to give specific advice. The old care plans of some of the service users indicated that health care professionals had given specific advice which the staff were appropriately continuing to follow. All of the service users have been registered with the local GP service. The members of staff spoken with said that the GPs had been very responsive to their requests for medical attention. Two of the service users have recently been admitted to hospital because of physical health care needs. Members of staff said that the medical support had been good. Whilst these service users were in hospital they were supported by their own care staff to ensure that their personal preferences were met thus, allowing the nursing and medical staff to offer appropriate care. Evidencing whether service users had recently attended dental, opthalmic and chiropody services was not possible because of the age of the care plans. However, a member of staff who knew the service users well was able to confirm that appointments were being arranged for the service users. The service has clear policies and procedures with regard to the ordering, storage and administration of medication. The MAR recoding sheets were reviewed and found to be accurately completed. The administration of medication was observed by the inspector and the procedure was carried out as the homes policy requires. Members of staff are only permitted to give medication if they have been assessed as competent to do so. DS0000051756.V325863.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. The home has clear policies and procedures with regard to complaints and safeguarding vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The provider has a well-established complaints policy and procedure which has been implemented at this home. There have been no complaints to the home or the Commission for Social Care Inspection since the service opened in November 2006. Only one service user survey was returned to the Commission for Social Care Inspection, this had been completed by a carer. They clearly indicated that the knew how to make a complaint but had never had the need to do so. The provider has a well-established policy and procedure with regard to the safeguarding of vulnerable adults and this is being implemented at the home. Members of staff also receive training to ensure they understand their responsibilities with regard to the reporting of any untoward issues that could affect the delivery of care to the service users. Not all members of staff have received is training although evidence was seen to support the position that training in this aspect of care delivery was being applied for. DS0000051756.V325863.R01.S.doc Version 5.2 Page 18 In discussions with members of staff on duty at the time of the site visit all were familiar with the complaints procedure and the safeguarding of adults procedure. One of these members of staff had only been employed within the past few months yet their knowledge was good. DS0000051756.V325863.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. The service does provide a homely, comfortable, clean and safe environment for the service users to live within. It is spacious and is well equipped with aids and adaptations to assist the service users. The only exception being the provision of a communal shower facility. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The communal areas of the home are spacious and are easily accessible to all the service users. Members of staff confirmed the ease of access. During the site visit it was clear that the movement of service users around the home is easily achieved whether they require wheelchairs and walking frames or using their own mobility. The home is equipped with a good range of aids and adaptations to meet the needs of the service users. DS0000051756.V325863.R01.S.doc Version 5.2 Page 20 There is only one communal bathroom area, which is equipped with a specialist bath and full hoisting equipment. Whilst the bath has a shower attachment for hair washing and body rinsing it does not facilitate a full shower. Evidence of the site visit demonstrated that for one service user their preference was to shower in a conventional shower and this was not available in the communal facilities. The manager should review the provision of bathing and showing facilities within the home to ensure there is sufficient provision to meet the needs and wishes of all the service users. The home was clean and hygienic. The manager has indicated in the preinspection questionnaire that policies and procedures are in place to ensure the control of infection and the safe handling and disposal of clinical waste materials. Comments in the one service user survey returned said that the home was always spotless and tidy. DS0000051756.V325863.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. There are sufficient members of staff to meet the needs of the service users. The provider has a robust recruitment procedure to ensure the service users are cared for by competent people. Some members of staff require further training, this has been identified by the manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The pre-inspection questionnaire completed by the manager identifies that there are sufficient staff employed to meet the needs of the service users. As the manager was away at the time of the inspection this matter was discussed with the area manager and she considers that the staffing establishment for the home does meet the needs of the people who live there. The manager also confirmed in the pre-inspection questionnaire that 75 of the care staff have an NVQ 2 or above. At the time of the site visit one senior member of staff was on sick leave and another member of support staff were subject to disciplinary action (this did not concern the delivery of care to service users). DS0000051756.V325863.R01.S.doc Version 5.2 Page 22 Bank staff from the provider organisation are being used to cover the absences. The provider organisation has a clear recruitment procedure to safeguard the well being of the service users. At the site visit the records of the most recently recruited member of staff were reviewed and found to contain all the information required by regulation. With the exception of one member of staff there was evidence that Criminal Record Bureau (CRB) checks had been completed on all staff members. Subsequent to the site visit CSCI have received confirmation from the area manager that an error in adminstration had occurred in transposing the information to the homes records and the member of staff has had a full CRB check. Members of staff are receiving training as there was evidence in their training records. Deficits have been identified and evidence was seen that the training was being applied for or was highlighted as needing to be applied for on the managers return from leave. DS0000051756.V325863.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. The home is run by a qualified and experienced manager however, the service does not have a Registered Manager. The home does have quality assurance systems in place to ensure the home is safe for the service users and members of staff. Some members of staff still require manadatory training with regard to safeguarding the health and safety of all who live, visit and work in the home. This judgement has been made using available evidence including a visit to this service. DS0000051756.V325863.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager is competent and qualified to run the home. She was not present during the site visit as she was on annual leave. However, she had completed the pre-inspection questionnaire and evidence of her management skills were seen in the procedures put in place at the home. At the time of the site visit she had not applied to be the Registered Manager. The provider organisation must ensure that a suitable candidate is put forward for registration. The provider organisation has an established quality assurance procedure in place which the manager adheres to. Evidence was seen of monthly provider visits; regular monitoring of processes and systems within the home to ensure its smooth running; staff meeting; consultation with the service users carers and professionals with regard to the service offered and how or if it needed to be altered. The evidence from the one CSCI survey indicated that the carers felt fully consulted and included in the decision to close the previous home their relative had lived in and their transfer to this home. These carers were visiting the home at the time of the site visit and affirmed their complete satisfaction with their inclusion in the management of their relatives care needs and their transfer to the home. In discussions with member of staff on duty during the site visit they confirmed that they had felt supported during the transition from the previous homes they had worked in to this home. There was also evidence that the area manager had contacted carers after the service users had moved into the home and she had received many favourable comments about their inclusion in the process. The evidence in the pre-inspection questionnaire indicated that the majority of the precautions required to ensure the home was safe for service users and members of staff had been achieved. A random sample of record were reviewed in the home and they confirmed that precautions are taken. Subsequent to the inspection the area manager has been able to confirm that the outstanding precautions had been actioned and imminent dates had been identified for their completion. As previously referred to not all members of staff have achieved the required training. Some of this training includes mandatory training with regard to health and safety issues. Evidence was seen that these deficits had been identified. As the deficits concern mandatory training a requirement for action will be necessary. DS0000051756.V325863.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 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 2 3 3 X 2 X 3 X X 2 X DS0000051756.V325863.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 YA6 Regulation 15 Requirement The Responsible Person must ensure that all service users must have relevant and up to date care plans that reflect their care needs for the service they live within. They should be reviewed as soon as changes to the service users care occur. They should be regularly reviewed. The Responsible Person must ensure that all service users must have relevant and up to date risk assessments. In addition to regular reviews they should be reviewed as soon as changes occur. All members of staff must be familiar with the assessed risks of the service users. The Responsible Person must ensure that all service users have their personal healthcare needs updated in their care plans. The Responsible Person must ensure that the home has sufficient bathing/showering facilities to meet the needs of the service users and to protect DS0000051756.V325863.R01.S.doc Timescale for action 28/02/07 2 YA9 13(4) 28/02/07 3 YA18 12(2&3) 28/02/07 4 YA18 YA24 23(2)(j) 31/03/07 Version 5.2 Page 27 their privacy and dignity. 5 YA37 9 The Responsible Person must ensure that a suitable candidate applies to be the Registered Manager of this service. The Responsible Person must ensure that all members of staff who require mandatory training receive it promptly to ensure that safe working practices are adhered to. 31/03/07 6 YA42 18(1)(c) 31/03/07 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 Refer to Standard YA1 Good Practice Recommendations The home manager completes the Statement of Purpose and Service User guide and provides copies to the existing service users and their carers and sends copies to the CSCI. The manager ensures that the applications for member of staff to receive appropriate training to meet the needs of the service users are completed when she returns from leave at the end of January 2007. 2 YA35 DS0000051756.V325863.R01.S.doc Version 5.2 Page 28 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. 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