Inspection on 30/11/06 for Briarwood Drive, 69

This inspection was carried out on 30th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Briarwood Drive, 69 19/12/05

Briarwood Drive, 69 28/06/05

Briarwood Drive, 69 14/09/04

Briarwood Drive, 69 05/05/04

Briarwood Drive, 69 23/02/04

Briarwood Drive, 69 22/07/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Briarwood Drive, 69 Santa Care Homes 69 Briarwood Drive Northwood Hills Middlesex HA6 1PW Lead Inspector Sandy Patrick Unannounced Inspection 30th November 2006 11:00 Briarwood Drive, 69 DS0000027085.V315282.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 Briarwood Drive, 69 DS0000027085.V315282.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. Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Briarwood Drive, 69 Address Santa Care Homes 69 Briarwood Drive Northwood Hills Middlesex HA6 1PW 01923 450 851 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) Santa Bapoo Santa Bapoo Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user who is visually impaired can be accommodated, as agreed by the Commission for Social Care Inspection, on 27th June 2005. The condition of registration will only apply for as long as the service user`s assessed needs can be met. The home must advise CSCI when the service user no longer resides at the home. 19th December 2005 Date of last inspection Brief Description of the Service: 69 Briarwood Drive is registered as a care home for three people who have a learning disability. The home is privately owned by Santa Care Homes, a small organisation who own and manage two other care homes locally. All the people who live at the home have their own bedroom. They share communal facilities including a well maintained garden. The home is situated close to local shops and public transport. There is 24 hour staffing and they provide support and care as needed. The Registered Person has produced a Service User Guide which outlines the Aims and Objectives of the service. The people who live at the home are supported by local authority funding and the current fees range from £850 to £1,250 per week. Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection visit took place on 30th November 2006. The Inspector met with two of the people who live at the home and the staff on duty. The Registered Manager and Deputy Manager were not on duty at the time of the inspection. However, a Deputy Manager from another home came to help the Inspector find out the information she needed. The Inspector spoke with one person who lives at the home and the staff, examined records and looked at the environment. Following the inspection visit the Manager contacted the Inspector to discuss further information. The Inspector gave the people who live at the home and the staff questionnaires about the service and left questionnaires for relatives and visitors. Two of the people who live at the home completed questionnaires with some help from staff. They said that they liked living there and that they were treated well by staff. They said that the staff listened to them and acted on what they said. Both people knew who to speak to if they were unhappy about anything. Four members of staff completed questionnaires. They said that they were well supported and given training. The staff were asked to comment on what they felt the home did well. Some of the comments were, ‘The staff have training and work as a team. Service users are given support and privacy’, ‘the skills of management are excellent and I am given support. All the staff are trained and work as a team’, ‘the home make sure all our service users satisfied and they feel comfortable. They are happy here’. The staff were asked to comment on any areas they felt the home could improve. One person said that they felt it would be good to have more indoor activities for the people who lived there. Throughout the day the staff treated everyone with kindness and respect. The atmosphere was calm and relaxed. What the service does well: People who live at the home are happy there. The staff feel supported. People are able to celebrate their culture and religion. The Manager is committed to improving the service. Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Briarwood Drive, 69 DS0000027085.V315282.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 Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who are thinking about moving to the home are given a range of different information and are able to visit and spend time there. Their needs are assessed by the Manager and other care professionals. EVIDENCE: The Registered Person has developed a Statement of Purpose and Service User Guide. These include information on staff qualifications and experience, admission criteria, fees and how to make a complaint. Two of the people who live at the home completed questionnaires about the service. They both said that they had been given a choice about moving there and had been given information to help them make this choice. One person had moved to the home shortly before the inspection. There was a range of information on the needs of this person and an assessment from their funding authority. A care plan has been developed. This includes information from the assessment. Briarwood Drive, 69 DS0000027085.V315282.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual needs are recorded within care plans but the people who live at the home have not been involved in the development of these and they are not recorded in a format which they can understand. The people who live at the home need more support to understand information and to communicate with staff. Risk assessments are in place and some of these are necessary. However, some restrict people. The staff need to look at how they can enable people to take risks. EVIDENCE: Each person has a care plan which details some of their needs. These are reviewed regularly. The care plans did not all contain information on people’s Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 10 likes, dislikes and social needs. These should be included and the staff should consider how best to meet these needs. Some of the care plans needed to be reorganised and older information archived, as current care needs were not always clear. Care plans and medication records should include a photograph of the individual they belong to. The home does not adopt a person centred approach to care planning. This is an area they need to improve. The people who live at the home should be involved in planning their own care and identifying their needs. Care plans should be recorded in a format which can be understood by each individual as well as the staff. The Manager should arrange for the staff to have training in this area and they should support individuals to have more control over their own lives and the care that they receive. In the questionnaires about the service, one person who lives at the home said that they always made decisions about what they did each day the other person said that they sometimes made decisions. Both people said that they could do what they wanted during the day and evening. One person has a visual impairment. The Deputy Manager said that a national charity for people with visual impairments had offered training and support to the staff. The staff explained that they had learnt information about how to keep the environment hazard free and how to use bright colours and other stimulation to help orientate this person. One person is deaf. They have learnt some signs and use these to communicate with a social worker who visits regularly. Some staff have had training in Makaton and signing. The staff said that this person prefers to communicate with them through writing notes. The Inspector saw examples of this as the staff and this person communicated about various things during the day. All staff should have training in Makaton and signing. The staff should use signs in addition to writing notes to support greater understanding and communication. One person does not speak English. Staff who speak their first language are employed for part of the day to offer them individual support. The other staff should learn some basic words in this person’s language so that they can communicate with them as well. Improvements should be made to a range of documents and information to make them more accessible to the people who live at the home. These include care plans, risk assessments, contracts, the complaints procedure and the Service User Guide. The staff should consider how they could use easy words Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 11 and pictures, recorded information and different languages to make it easier for people to understand. One person who lives at the home smokes and drinks alcohol. Risk assessments and a care plan are in place to make sure this person receives the support they need. One person is sometimes physically challenging. The staff have had training so that they can offer the right support to keep this person and others safe. Risk assessments are in place. The staff said that one person is at risk from using the kitchen and therefore they are not allowed in this room. This should be reviewed and an enabling plan which looks at how the risks for this individual could be reduced so that they are free to use the kitchen should be developed. The staff should focus on how people can be enabled to take risks and how these can be safely managed rather than restricting people in order to eliminate risks. Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Two of the people living at the home have fulfilling lives which meet their needs. However, one person’s social, leisure and educational needs are not being met and they need more support in this area. People who live at the home use the local community and their religious and cultural needs are met. Everybody has contact with family members and see them regularly. The staff treat the people who live at the home with respect. A range of healthy and freshly prepared food is available. Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 13 EVIDENCE: The people who live at the home are not involved in many household tasks or cooking. The staff should consider how they could support individuals to learn new skills and to be involved in these areas where appropriate. One person said that they would like to have more people to talk to and to socialise with. They said that they would like more opportunities to meet people outside of the home. They said that their social worker was looking at day centres, which they might like to attend. It is very important that this person is given the support they want and need in this area. One person said that sometimes they went out on day trips in the house vehicle to places of interest. They said that they sometimes went with people from other houses and they liked this. One person said that, ‘we have to go where the other people want to go’. These trips are clearly enjoyed by some people, however the staff should make sure everybody has a choice about where they go on day trips and their opinions are listened to. One person who has a visual impairment has audio books delivered regularly. The staff said that the machine to play these was broken at the time of the inspection. This should be repaired. There are limited activities in the home and the people who live there have very different needs. There are barriers to them communicating with each other. Two people have set routines which they like to stick to each day, but one person does not have any structured routine. They told the Inspector that they would like more things to do and more people to talk to. The staff should look at how they can support this person. One person suggested that there could be more activities and things to do in the home. The staff should consider purchasing a range of leisure equipment and resources which the people who live there would find interesting and fun. The staff said that they support people to use the local community and they go to the shops and other local places regularly. On the day of the inspection one person went to local shops and choose the food they wanted for lunch. The staff completing questionnaires said that they felt equality and diversity issues were managed effectively. The people who live at the home have different religious and cultural needs. One person is visited by the Salvation Army and attends church when they choose to. The staff said that they support them with this. Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 14 One person attends a local centre each day which meets their cultural and religious needs. They visit a Temple with their family. One person is a practicing Hindu and does not speak English. They have a separate fridge for their food and a member of staff who is familiar with their cultural needs is employed to prepare their meals and to communicate with them using their first language. Their care plan states their religious and cultural needs and the staff on duty were aware of these. Everyone has contact with their family. Throughout the day the Inspector saw the staff treating the people who live at the home with respect and kindness. The staff prepare meals and record what everyone has eaten. People are able to choose the food they want and one person said that the quality of food is good. Briarwood Drive, 69 DS0000027085.V315282.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 good This judgement has been made using available evidence including a visit to this service. Personal and health care needs are recorded and met. Medication is appropriately managed. EVIDENCE: Personal care needs are recorded within care plans. Everybody is registered with a local GP and other health care professionals as needed. A record of all health care appointments is kept within care plans. Staff knew about the different health care needs of everybody and they monitor these as needed. There is a suitable medication procedure. Medication is stored, recorded and administered appropriately. The staff have had training in medication. Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. A complaints procedure and protection of vulnerable adults procedure are in place but these are not available to staff or the people who live at the home. EVIDENCE: There is an appropriate complaints procedure which details timescales and how to contact the Commission for Social Care Inspection. This is not recorded in formats which the people who live at the home can understand. There have been no formal complaints since the last inspection. Both of the people living at the home who completed questionnaires said that they knew who to speak to if they were unhappy about anything. The Deputy Manager said that the home had a copy of the local authority protection of vulnerable adults procedure. However, this was not available to see and the staff did not have access to it. The Manager must make sure the procedure is in place and the staff can access it at any time. The staff have all had training in protection of vulnerable adults and one member of staff spoke about this with the Inspector. Appropriate checks are made on staff, including criminal record checks, before they are employed. Everybody has their own bank account and the staff help them to manage their money. Small amounts of cash are kept safely at the home. Records and Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 17 receipts of transactions are kept. These would benefit from auditing as a large amount of receipts are held in one place. The people whose money it is are not involved in checking it or dealing with transactions. The staff should consider ways in which they can support individuals to be more involved in managing their own money. Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 18 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, 25, 26, 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a comfortable and generally well maintained home. Some areas of repair and redecoration are needed. Improvements should be made to personalise the home and make it more attractive and homely. EVIDENCE: The home is a four bedroom property in a residential road, close to local shops and public transport. Roadside parking is available. One bedroom is on the ground floor and three are on the first floor. One bedroom is used for the staff. Everybody has their own bedroom. There is a large lounge/dining area, a bathroom, two separate WCs and a well equipped kitchen. A converted garage is used as a utility room. There is a garden mostly laid to lawn. Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 19 The Owner is considering making changes to the property to create a new bedroom with en suite bathroom for one person. In general the house is well maintained although there are areas which need to be repaired or redecorated. Some of the paintwork is damaged, the stair carpet needs to be replaced, the curtains in one bedroom were falling down and the flooring in the WC and bathroom is damaged. One person at the home finds it hard to allow pictures and ornaments to be displayed and has caused a lot of damage to the environment. Because of this some areas of the home are rather bland and lack personal features. The staff should consider other ways to decorate the home and make it more homely and attractive, such as using murals and a variety of colours and textures. Consideration should also be given to using sensory equipment to help make the home more attractive and create a calming atmosphere. The Inspector saw one person’s bedroom. This was also plain and lacked features and colours. The curtains in this room were falling down and the paintwork was old and needed renewing. This person has a visual impairment and the staff on duty spoke about the training they had undertaken and how they had learnt about the importance of using colour and other stimulation to support orientation. They should consult with the person in this room about how they can make the room more attractive and appealing to them. In general the home was clean and fresh. Staff were cleaning when the Inspector arrived and said that they did this daily. However, there was no soap in either the bathroom or WC. The staff must make sure this is available. Both of the people living at the home who contacted the Inspector said that they thought the home was always clean and fresh. Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at the home are supported by competent and qualified staff. The staff feel supported and have regular training. EVIDENCE: The home was fully staffed at the time of the inspection. Two members of staff were on duty. A third member of support staff works specifically with one person to support them with their cultural and dietary needs. They also speak the same language as this person and help them to communicate their needs to others. A full time Deputy Manager is employed and the Deputy Manager from another home offers support as needed. The home does not use agency staff. The people living at the home said that the staff treated them well, listened to them and acted upon what they said. One person mentioned some staff by name praising them for their kindness and support. Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 21 The staff who completed questionnaires said that they were well supported and had regular formal supervision as well as informal support. They said that the Manager was always available to offer advice and support. The staff described thorough recruitment procedures stating that they attended a formal interview and undertook a full induction. There have been no new staff employed since the last inspection. The Deputy Manager and Manager interview all staff. The recruitment records for staff were not available to view at the inspection. However, recent inspections of other Santa Care registered homes have found that recruitment procedures are sound and that staff files are complete. Thorough checks are made on staff before employment. The staff said that they had attended a range of training and some staff were undertaking NVQs. Training records show that all staff have undertaken key training including first aid, protection of vulnerable adults, understanding autism, medication and health and safety. The Deputy Manager at Briarwood Drive and the Deputy Manager from the other home have both undertaken NVQ Level 4. All the staff have completed induction training and two of them have started taking NVQ Level 2. There have been no recorded staff meetings since 27.01.06. The staff said that they felt supported. Informal support and guidance is important and should continue. However, it is also important to have formal meetings for the team. Supervision records were not available to look at during the inspection visit, however staff said that they had this regularly. Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 22 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, 38, 39, 41 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. There are suitable procedures to maintain good health and safety. The staff need to make sure these are followed at all times. EVIDENCE: The Owner is also the Registered Manager. She is experienced and has worked with people with learning disabilities for over twenty years, managing homes for sixteen years. She is qualified to NVQ Level 4 and is a Registered Nurse. She has undertaken a range of relevant training. Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 23 The Deputy Manager takes a lead role in the day-to-day management of the home and gives the staff support and supervision. He is qualified to NVQ Level 4 and has undertaken the Registered Managers Award. He is suitably experienced and keeps himself updated with training in key areas. The Deputy Manager from another home offers additional support and helps to oversee the home in the absence of the other managers. On the day of the inspection she was working at the home and assisted with the Inspection. She demonstrated an excellent knowledge of the individual needs of each of the people living there. The staff on duty said that they felt supported by her and confident in her management. The staff completing questionnaires and those who spoke with the Inspector praised the Manager and the support they received. One person wrote, ‘I would like to thank the management who make our work easy and comfortable’. The staff felt that they were able to contribute to decision making and were involved in quality monitoring. Some incidents and accidents had happened since the last inspection. These included one person going missing. The Manager must make sure the CSCI are notified of any such event. The policies and procedures at the home are stored in a locked cabinet which staff cannot access. They should be available for staff to access them. The cupboard for storing cleaning products had been broken and could not be locked at the time of the inspection. These products must be locked away in accordance with COSHH (Control of Substances Hazardous to Health) Regulations. Regular checks on health and safety, including fire safety and food storage temperatures are made and recorded. Briarwood Drive, 69 DS0000027085.V315282.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 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 2 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 2 3 3 X 2 X Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 12(2)&(3) 15 16(2)(m) Requirement Timescale for action The Registered Person must 31/03/07 introduce person centred planning where each person is involved in developing and reviewing their own care plans. Care plans must include information on likes, dislikes and social needs. Care plans must be available in a format which can be understood by the person they are written about. 2. YA7 12(5)(b) 18(1)(c) The Registered Person must 31/03/07 arrange for all the staff to learn Makaton and some basic words in the language one person speaks so that they can communicate with the people who live at the home. Care plans, the Service User 31/03/07 Guide, contracts, the complaints procedure and DS0000027085.V315282.R01.S.doc Version 5.2 Page 26 3. YA7 5(2) 12(2)&(3) 15 Briarwood Drive, 69 22(2) other key documents should be recorded in formats which the people who live at the home can understand. The Registered Person must 31/01/07 look at how people who live at the home can be enabled to take risks and should not restrict people unnecessarily. 4. YA9 12 16(2)(h) 5. YA12 12 The Registered Person must 31/01/07 16(2)(m)&(n) make sure the social and educational needs of people who live at the home are met and that they have full and active lives which meet their needs. 13(6) The Registered Person must 31/12/06 make sure the local authority protection of vulnerable adults procedure is in place and is accessible to staff. The Registered Person must 31/03/07 attend to the decorative and repair needs identified. The Registered Person must 31/12/06 make sure soap is available for people to wash their hands in the bathrooms and WCs. The Registered Person must 31/12/06 notify the CSCI about any event which effects the well being of the people who live at the home. 6. YA23 7. YA24 23(2)(b)&(d) 8. YA30 12(1) 13(3) 9. YA38 37 Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 27 10. YA42 13(4)&(6) The Registered Person must 31/12/06 make sure COSHH products are stored securely. 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 YA6 Good Practice Recommendations Care plans should be reorganised and old information should be archived so that they are clear and easy to understand. Care plans should contain a photograph of the individual. 2. YA11 Staff should support the people who live at the home to learn new skills and to be involved in day-to-day activities. The staff should make sure everyone is able to choose where they want to go on outings and that their opinions are listened to. The audio book machine used by one person should be repaired. The Manager should consider purchasing a range of leisure equipment, games etc that people who live at the home can use when they want. 4. YA23 People who live at the home should be supported so that they can be involved in managing their own money where possible. The staff should think about how they can make the house more attractive and homely, in bedrooms and communal areas. DS0000027085.V315282.R01.S.doc Version 5.2 Page 28 3. YA14 5. YA24 Briarwood Drive, 69 6. YA36 Regular team meetings should take place and be recorded so that staff can discuss the needs of people, procedures and routines as a group. The policies and procedures should be stored somewhere staff and the people who live at the home can access them. 7. YA40 Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Briarwood Drive, 69 DS0000027085.V315282.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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