Inspection on 12/02/07 for Brightwater

This inspection was carried out on 12th February 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Brightwater 13/02/08

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 Brightwater 3 Otter Close Bishopstoke Eastleigh Hampshire SO50 8NF Lead Inspector Mr Rodney Martin Key Unannounced Inspection 13th February 2007 10:00 Brightwater DS0000068060.V323785.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 Brightwater DS0000068060.V323785.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. Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brightwater Address 3 Otter Close Bishopstoke Eastleigh Hampshire SO50 8NF 023 8064 4920 023 8005 1205 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) In Chorus Limited Debora Lyon Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: Brightwater is owned by “In Chorus Ltd” that also owns 2 other care homes for young adults in the same Borough Council area. It is located in a quiet residential area close to local amenities. These consist of local shops, surgeries, public house and a bus service that provides access to Eastleigh town centre where there is a rail service that is connected to the national network. The building was constructed in the early 1990’s and it is a 2 story semidetached family house that has been extended. The accommodation consist of 3 single bedrooms on the 1st floor that are all provided with en-suite showers and WCs. There are 2 large communal rooms and a kitchen on the ground floor. There is a small and enclosed front garden and a small rear garden that is almost completely filled by a swimming pool. The home is registered to provide personal care for up to 3 young adults in the category of learning disability. All potential residents are referred to the service by statutory agencies i.e. a Primary Care Trust or the Adults Services Department of a local authority. They then are sent a brochure with information about the services that the home provides and invited to visit and look at the home. At such a visit they will be shown a copy of the most recent inspection of the home made by the Commission for Social Care Inspection (CSCI) and also referred to the CSCI website. At the time of a site/fieldwork visit to the home on 12th February 2007 the fees ranged from £1077 to £1225 per week, and this did not include the cost of toiletries, leisure activities and transport. Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site/fieldwork visit was part of the process of the first key inspection of the establishment since it was first registered and began operating in September 2006. It took place on 12th February 2007, starting at 09:20 and finishing and 13:40 hours. During the visit the accommodation was viewed including bedrooms, communal/shared areas and the home’s kitchen and laundry facilities. Documents and records were examined and residents, staff and health and social care professionals were spoken to in order to obtain their perceptions of the service that the home provided. At the time of the visit the home was full, accommodating 3 residents. They all had Autistic Spectrum Disorders or Asperger’s Syndrome and were male and aged in their early 20’s. None was from a minority ethnic group. The home’s registered manager was present throughout most of the visit and was available to provide assistance and information when required. Also present for some of the visit was the responsible individual who represented the company that owned the home. Other matters that influenced this report included a pre-inspection questionnaire with documentation completed and provided by the registered manager and comment cards completed by all the residents. Also information that the Commission for Social Care inspection had received since the home was first registered in September 2006, such as statutory notices about incidents/accidents that had occurred. What the service does well: What has improved since the last inspection? This was the first inspection of the home. Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 6 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. Brightwater DS0000068060.V323785.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 Brightwater DS0000068060.V323785.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): 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a system for identifying the help and assistance that potential residents need before they move into the home to ensure that the level of support they require can be provided. EVIDENCE: The home had a written procedure about admission to the establishment and it included reference to how the home would identify the level of help a potential resident required. This would included an “assessment stay” i.e. a period spent at the home of a minimum of 2 nights as well as obtaining information about the person from the “applicant” as well as other relevant personnel such as the Adult Services Department of the Local Authority and healthcare professionals. The home’s registered manager said that she would visit potential residents where they lived and “ meet with them and observe them to see if they would fit in and be appropriate for Brightwater”. The records of the 3 residents accommodated at the home were examined. It was apparent from the documentation and also from discussion with residents and staff that the move of the individuals into the home had been well planned and prepared. There were comprehensive assessments of the needs of the individuals that identified the support and assistance that each required with a range of day to matters. The assessments included the views of all interested parties including where relevant healthcare professionals and relatives. At the time of the site/fieldwork visit the responsible individual representing the company that owned the home was showing the relatives and care Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 9 manager/social worker of a potential resident around the premises and discussing with them what the service could provide. There was documentary evidence that transitional plans had been implemented as part of the process when the individuals living at Brightwater were preparing to move from their previous accommodation into the home. Some of the staff working in the home had also worked with some of the residents where they had lived previously. This had provided some continuity of support for individuals that can experience difficulty when faced with something new or a change of circumstances. Comments from residents and staff about the assessment process and admission to or move into the home included the following: • “I was made an offer of moving into Brightwater by the director who runs the 3 homes and I was and still am very pleased to live at Brightwater. I feel that the previous home wasn’t meeting my needs but I think that Brightwater is as there are more people of my own ability especially socially”. • “I worked with the residents where they lived previously so I got to know them and they got to know me”. Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had systems and procedures in place that ensured that: Detailed plans were agreed with individuals setting out the support they required. Individuals were supported to make informed decisions about their preferred lifestyle. Potential risks to individuals were identified and strategies were agreed with the persons concerned to minimise harm. EVIDENCE: The documents/records examined concerning the home’s 3 residents included individual plans outlining the help and support that the home’s staff would provide with day to day living and also in accessing the community. There was evidence from both documents and discussion with residents that they were involved in the development of the plans and subsequent reviews of them and had read and signed them. Plans set out agreed goals that each resident had agreed that they wanted to achieve and how staff would provide the support needed for them to do so. The home employed a key worker system with a member of staff allocated responsibility for providing support with specific matters concerning an Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 11 individual resident. Records were kept by key-workers that referred to certain area of responsibility such as; checking an individuals toiletries, clothing and accommodation; noting achievements; time spent with the resident; contact with family and friends; and any help with personal hygiene that may be necessary. There was evidence that plans were reviewed at least monthly and some targets for achievement agreed with residents were reviewed weekly. Comment cards completed by all the residents indicated that they were all of the view that they were able to make decisions about what they wanted to do each day. One individual stated: • “The only things I can’t do are keep alcohol in the main fridge and go out to nightclub alone”. One individual was involved in a self-help/advocacy group and the home’s registered manager said that participation in this or similar groups was being discussed with the other residents. Potential risks to residents were identified arising from any routines and activities that they were involved including daily living skills as well as their leisure interests and using amenities in the community. Detailed plans/strategies were implemented in order that such risks were eliminated, reduced or managed appropriately. It was apparent that these risks were reviewed and plans amended when necessary. One example concerned the degree of support required to enable a resident to use public transport to college. This had been reduced following a review when it had been agreed that he had overcome anxieties that had necessitated being accompanied by staff when travelling. One social care professional said the following about the progress he had noted that the home had made working with one of the residents who was also his client. • “I was very impressed when I saw D…my client is very happy. He is doing a lot more for himself and support workers help him go out in the community …”. A member of the local community mental health team expressed similar views about progress that another resident had made. Brightwater DS0000068060.V323785.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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home encouraged and supported residents to: access and use amenities in the local community; participate in a range of activities including education and work placements; and to maintain links with families and friends. Residents’ rights were promoted by the home and they were supported to eat healthily. EVIDENCE: Living at the home was conditional upon an individual taking part in vocational activities on 2 different days i.e. either work placement or adult education. All 3 residents were participating in either further/adult education or work experience. It was apparent that individuals selected their preferred option as on resident said that he was not interested in going to college and consequently was involved in voluntary work in the local community. Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 13 The home had a number of written policies and procedures including one about “community participation” which included an annexe with details about a range of community amenities available to residents. Comment cards completed by residents indicated that they were able to make use of local services and facilities and one individual stated: • “I go to the shops on my own”. One residents not only attended a college course but had was also regularly going to a local leisure/sports centre and was following a personal fitness programme in which he had made considerable progress. The home’s registered manager stated that residents would be supported to exercise their civil rights to be politically active and vote if they wished to do so. The home had policies about “Visitor” and “Relationships” and there was a sign in the entrance hall of the home indicating that visitors were welcome. At the time of the fieldwork/site visit one resident was going out to spend the day with a relative and the home’s registered manager said that most weekend at least 2 of the residents stayed with relatives. Residents not only participated in courses at local colleges or work placements but also used facilities in the local community including sports centres, pubs and nightclubs. On such occasions they had opportunities to meet people and make friends with other people. The contract/licence agreement issued to all residents setting out the terms under which they were accommodated in the home included the following statements: “You can keep your own key to your room and keep it locked if you want to”. “No one is allowed in your room when you are in it without your permission. When you are in your room. Staff will knock and wait for you to say if they can come in. You can ask them not to come in if you prefer”. “You have been provided with your own key for the main entrance door and front gate of Brightwater. This key will allow you to access the house independently”. “You must share with other residents the household duties, such as: diner jobs, cleaning the house and swimming pool, gardening etc., following rotas”. Residents spoken to confirmed that they were involved in household tasks and shared the responsibilities and with staff support and advice these also included activities such as menu planning, preparing meals and shopping for food and other household items. Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 14 The menus seen during the fieldwork/site visit indicated that the residents generally ate a varied and balanced diet. The home’s registered manager said: • “There is a rota for housekeeping chores and they take turns. The residents plan the menus and J then produces them on the computer. They insisted on having fish and chips every Friday. One has fish with a sauce the others have fish in batter. They make a list for the shopping. Sometimes they will decide to have a take away meal for a change”. It was suggested that the licence agreement/contract issued to residents included details about the home’s policy concerning, smoking, alcohol and drugs. Brightwater DS0000068060.V323785.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensured that residents’ personal and health care needs were promoted and that their medication was managed safely. EVIDENCE: At the time of the site/fieldwork visit the support that the residents accommodated at Brightwater needed with personal care was limited to advice and prompting with some aspects of personal hygiene. The contract/licence agreement issued to each resident included the following statements: “Getting up times are between 8:30 am-9:00 am, Monday to Friday, Breakfast time finishes at 9:30 am. This rule doesn’t apply on weekends, bank holidays and during your 6 week holidays, for which there are no set getting up times. You must get up and be ready earlier if necessary for a particular activity e.g. college, work placement, etc”. “You will have a local doctor. Your doctor’s name is … The dentist, chiropodist and optician all visit Brightwater or you might prefer to go out for your appointment. We can also ask other people to help, such as community nurses and psychiatrists”. Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 16 There was evidence from records/documents and from discussions with residents that they saw health care professionals when they were unwell as well as for regular health checks or when they sought advice about health concerns such as giving up smoking. All staff working in the home had received training in the management of medication and the home had a system in place for ensuring that medication was managed safely. At the time of the fieldwork/site visit no resident had been assessed as able to look after all their own medication safely. One resident did however say that his particular situation was due to be reviewed and that he did look after his own inhaler. The home had a written policy and procedure concerning the management of medication and all medicines were dispensed from their original containers. Patient information leaflets from medicines were retained and kept in the file of the resident concerned to ensure that information about the medication was readily available. Records were kept of the ordering, receipt, administration and disposal of medicines and they were accurate and up to date. A record of medication was signed off when staff shift changes occurred and specimen signature was available of all the staff involved in the administration of medication. The medication was stored in a locked metal cupboard in the staff room. It was suggested that the suitability of the cupboard be reviewed and particularly the security of its wall fixings. Brightwater DS0000068060.V323785.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had systems and procedures in place to address the concerns of residents and protect them from harm. EVIDENCE: The home had a complaints procedure and all residents indicated in comment cards that they returned to the Commission for Social Care Inspection (CSCI) that they knew who to speak to if they were unhappy and how to make a complaint. The licence agreement/contract issued to all residents included a simple section in it about “People You can Speak To” and the telephone number of the directors of the company that owned the home and contact details of the individual’s social worker/care manager and CSCI were also provided. The home kept records of complaints and none had been made to the home since it started operating in September 2006 and none had been received by the CSCI. The home had a written procedure about “Abuse Prevention” and related subjects e.g. gifts to staff, and all staff had received training in the subject/topic of adult protection. Brightwater DS0000068060.V323785.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s premises were well maintained and kept safe and there were systems and procedures in place to ensure residents were protected from the risk of infection. EVIDENCE: The home is located in an estate of privately owned housing and its purpose and use as a care home is not apparent as it cannot be distinguished in any way from surrounding properties. The local amenities include shops, a surgery, pubs and easy access to a bus service to the town centre of Eastleigh with transport links to the nearby cities of Southampton, Winchester and Portsmouth The accommodation and the facilities including furnishings are domestic in character. The interior and exterior of the premises were in good repair and well maintained and there were no offensive odours anywhere in the building at the time of the fieldwork/site visit. Visits to the home by the local fire and rescue service and environmental health officer in August and September 2006 respectively indicated that both agencies were satisfied with the premises and way that matters that they were concerned with were managed. Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 19 The home had several policies and procedure concerned with maintaining the environment including “Standards for residents Bedrooms” and “Repairs and Maintenance” and the latter included reference to “do-it-yourself decorating”. A washing machine and tumble drier were suitably located in the home’s staff room/office. The home had a written policy and procedure concerned with infection control and all staff had received training in health and safety subjects including infection control. Comment cards received by CSCI from the 3 residents accommodated at the home indicated that all believed that the home was always kept fresh and clean. Brightwater DS0000068060.V323785.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): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had procedures in place to ensure that staff were properly recruited, trained, and deployed in sufficient number to meet the needs of the residents accommodated. EVIDENCE: At the time of the fieldwork/site visit to the home it employed 5 staff including the registered manager. Out of the staff group (including the registered manager) 3 had obtained National Vocational Qualifications (NVQ) at level 3 in Care i.e. “Promoting Independence”. Comment cards received by CSCI from the 3 residents accommodate at the home indicated that they all believed that staff treated them well, and listened and acted on what they said. One stated the following: • “I think that the staff at Brightwater are hard working. We do sometimes have our disagreements however we get on well a lot of the time. The staff are very friendly people and I feel comfortable when my family visit me when the staff are around”. The induction training for all staff included an awareness of the specific needs of the group of residents accommodated at the home of the group i.e. Autistic Spectrum Disorder. Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 21 The home had a written policy and procedure concerned with staff recruitment that included references to the need to obtain at least 2 written references and a complete a Criminal Records Bureau for every applicant. The records of 2 staff were examined and it was apparent from the documentation that all the statutorily required per-employment checks had been completed before they had started work. The records examined indicated that staff had received structured induction over 8 weeks and had regular supervision meetings with their manager. At supervision meetings training needs and professional development was discussed. One member of the staff team said: • “I have been on training courses about Autism and Asperger’s syndrome, moving and handling, and we covered privacy and dignity, and fire safety”. Brightwater DS0000068060.V323785.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): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was effectively managed and there were systems in place for monitoring the quality of the service the home provided and ensuring that the health and welfare of people living and working in the home was promoted. EVIDENCE: The registered manager had been in post since the home started operating in September 2006. She had previously worked for the company that owned the home at another establishment as a team leader and also as a support worker. At the time of the fieldwork/site visit she had obtained NVQ level 3 in care and was working towards obtaining NVQ level 4 and the Registered managers Award. Staff spoken to appreciated the manager’s knowledge and experience and were confident in her abilities as well as appreciating her personal qualities. It was also apparent from discussion with the registered manager that she was enthusiastic, motivated and had a comprehensive understanding of the needs of the residents accommodated in the home. Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 23 One social care professional spoken to said the following about the management of the home: “I was very impressed when I saw D. The home is well done the manager is very good and my client is very happy… I could not fault it. There was a good relationship between the staff and management”. A member of the local Community mental health Team expressed similar views about the home and its management. The basis for monitoring the quality of the service provided by the home was monthly visits conducted by the responsible individual representing the company that owned it. These were carried out in accordance with Regulation 26 of the Care Homes Regulations 2001. During these visits audits of the home’s management systems and documentation were done. When a problem was identified during the visit it was documented and a target date was set for remedying the matter and completion date was recorded when it was done. Residents meetings were held in the home at which they could express their views and comment about day-to-day life in the whom and request changes to routines and activities. As the home had only been operating for some 6 months no service surveys had been completed in order to obtain the views of residents and other stakeholders/interested parties about the service that it provided. It was suggested that questionnaires could be used to obtain the views of everyone with an interest in the service. There was some discussion about the recently implemented legal obligation imposed on registered persons to complete an Annual Quality Assurance Assessment (AQAA). Comment cards returned to CSCI by the residents living in the home indicated that they all liked living in the home. There were a range of written policies and procedures readily available in the home that influenced staff working practice. One member of staff said: • “We have a lot more policies and procedures and they are helpful because sometimes I may not be sure about something and I can then look it up”. The home had a number of written health and safety policies and procedures. Records examined indicated that the home’s systems were checked and serviced at appropriate intervals i.e. fire safety equipment portable electrical equipment; and hot water system. Records were kept of accidents. Guards covered all radiators in the home. Staff spoken to said that they had attended fire safety and other health and safety training. There was evidence that all the residents living in the home had also completed training in fire safety and also had or were training in basic food hygiene. Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 24 There was a fire risk assessment for the premises and a regular risk assessments of the premises and working practices were undertaken. Brightwater DS0000068060.V323785.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 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 X X Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brightwater DS0000068060.V323785.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Brightwater DS0000068060.V323785.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!