Inspection on 24/06/08 for Byron Court

This inspection was carried out on 24th June 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Byron Court 13/06/07

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Byron Court 55 Chaucer Road Bedford MK40 2AL Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 24th June 2008 12:15 Byron Court DS0000068342.V367116.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 Byron Court DS0000068342.V367116.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. Byron Court DS0000068342.V367116.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Byron Court Address 55 Chaucer Road Bedford MK40 2AL 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) 01707 652053 01234 268917 www.caretech-uk.com CareTech Community Services Ltd Lesley Gray Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Byron Court DS0000068342.V367116.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2007 Brief Description of the Service: Byron Court service is part of Caretech Community Care Service Ltd. They are a large service provider and are already operating care homes in other regions. The service provides accommodation for up to six people with a primary diagnosis of learning disability. The property is situated close to the town of Bedford, with easy access to all major routes and close proximity to Luton and Milton Keynes. The fees for the service are from £1,600 per week for a room to £2,625 a week for a flat. Additional charges are made for transport costs. This is offset from the people’s mobility allowance. Byron Court DS0000068342.V367116.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 24/06/08 over 5 hours 50 minutes by Pursotamraj Hirekar. The deputy manager coordinated the inspection. The method of inspection included study of care plans, risk assessments, staff recruitment records, staff deployment duty rota, relevant care delivery documents, discussions with deputy manager, staff on duty, conversation with people using the service and partial tour of the building. The pre – inspection survey of people who use this service and staff responses, the annual quality assurance assessment (AQAA) – provider’s self-assessment and in response to the inspection feedback, telephonic conversation with the registered manager and the documentary evidence sent in by the registered manager, post this inspection is included for analysis and preparation of this report as well. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. What the service does well: What has improved since the last inspection? The registered manager and staff appeared to have made good efforts to comply with the outstanding requirements from the previous key inspection for example administration of medication and risk assessments of people living at the home. Byron Court DS0000068342.V367116.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. Byron Court DS0000068342.V367116.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 Byron Court DS0000068342.V367116.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 and 5 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. Assessments were completed to assess the care needs of people who live at the service. EVIDENCE: The Statement of Purpose was not made available on this inspection; the deputy manager tried to locate it, but could not, and said he will inform the registered manger on her return from leave. The registered manager informed us through phone, post this inspection that a staff member who was working for NVQ had taken it and had not replaced it on time. Therefore, it was not made available on the inspection. The registered manager had further stated that a revised and update version has been now sent to our office through fax on the 03/07/08. There has been no new admissions to the service since the last inspection. Therefore this standard could not be fully assessed. However 2 people using the service were case tracked. The pre admission assessment process and documentation had been archived. However, it was apparent from the care planning process, that the home had undertaken a full assessment of needs for Byron Court DS0000068342.V367116.R01.S.doc Version 5.2 Page 9 each of them. The needs assessment was also supported by a health and social services assessment. The method of assessment involved the person who used the service, the family, and other key stakeholders. There was also evidence that the home had regularly reviewed the assessments of need. The home was able to demonstrate that it could meet the assessed needs of people staying at the home. Staff individually and collectively demonstrated that they had the skills and experience to deliver the service and care which the home said it could provide. Staff was observed communicating with people using the service in different forms of communication to suit their individual preferences and needs. A contract had been prepared for each of the service users. However, 1 out of 2 people case tracked, did not have information about the cost and it was not signed. Byron Court DS0000068342.V367116.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 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The home had developed detailed support plans based on the needs and risk assessments of the people who use the service, to support all aspects of their lives. EVIDENCE: The care documents of 2 people using the service were seen. The support plan outlined the individual need with regard to their communication, personal care, household chores, mobility, likes and dislikes, nutrition, day services, cultural needs, emotional needs, retiring to bed and support requirement. The information was holistic and from the view of the people using the service in relation to their choice of lifestyle, needs and interests. The plans had been written in sufficient detail to ensure that anyone working at the home could provide the necessary care. Byron Court DS0000068342.V367116.R01.S.doc Version 5.2 Page 11 Information was written to help staff to provide the right level of support in relation to promoting independence and skills for daily living such as personal care, domestic tasks, and accessing the community. People using the service said staff knew their routines and choices. The daily routines presented in the support plans reflected in the daily reports of the people. The support plans were presented in an appropriate format to read and understand by the people using the service with communication needs, except for 1 person who was non verbal. Also the support plans could demonstrate how the people were engaged in the support planning and review process, except for 1 person who was non verbal. This was brought to the attention of the registered manager post this inspection. The registered manager had sent in a written confirmation to us which said that she will contact advocacy alliance requesting that an individual will support xxx by participating in the care plan and review process. Support plans were reviewed regularly, six monthly or as and when the need arouse and the changes reflected in the support plan. For example risk assessment for a person was carried out with regard to accessing the community alone, going to a show or concert and using the kitchen. And for another person risk assessments for travel in a vehicle, using kitchen, activities at home, accessing community, managing money and challenging behaviour was carried out. The staff working were aware of the changes to the support plan of the person. People using the services can access social and community activities locally, which include their daily routines; going to their place of work or day centre either independently or transport arranged and shopping. Observations made indicated the relationship between people using the services and staff is relaxed, friendly and polite, showing respect to each other when they are talking or expressing a view. The staff on duty said people make their own decisions or are supported through conversation to make their own decisions. For example, a member of staff was supporting a person to do her hair and get ready for a birthday party in the evening. The other people also appeared happy and well dressed for a birthday party in the evening. Byron Court DS0000068342.V367116.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 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. People who use the service experience and enjoy a lifestyle that suits them, being part of the community and having meals of their choice. EVIDENCE: Staff said people moving to the home are supported to continue participating in daily social and community activities. Information about individual daily, social and community activities are detailed in the assessment and included in their support plan. The people using the services, confirmed during the discussion that they continued to participate in daily activities ranging from the day services, college, going out socially with family and friends. People can choose how to spend the evening and weekends, ranging from seeing friends and family and Byron Court DS0000068342.V367116.R01.S.doc Version 5.2 Page 13 watching television or films. Activities and daily routines were reflected in the daily records and consistent with the interests recorded in the individual support plans and have also matched with today’s activity plan. People using the services indicated, they felt in control of their life at the home and were not restricted in what they did. For example, 1 person said that he has an interview for cooking course at Bedford College, and has been trying to gain more independence by going to town, and visit church with mum. Another, person said that staff support when her friend visit the home and help her understand about relationships. There was evidence that the home supported people who used the service to maintain family links and friendships inside and outside the home, in accordance with their wishes. People who were spoken with, who lived at the home, and who said that their families and friends could visit at any time supported this evidence. Staff demonstrated a good understanding of the people they key work, recognising if the person is anxious or unhappy, and how to approach them. People using the service spoken to, have said that they have the freedom to make choice of the meals and mealtime. Staffs have received training in preparation and safe handling of food. Staff said they always encourage the people to choose the meals. It was noted that the people were neatly dressed and that they were treated as individuals. Throughout the inspection staff were seen talking to people and treating them with dignity; The people using the service had a good rapport with the staff and the relationship between staff and the people appeared to be that of encouragement and supportive. Byron Court DS0000068342.V367116.R01.S.doc Version 5.2 Page 14 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 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The personal and health care needs of people, who use the service, are met promoting their independence and quality of life. EVIDENCE: The personal and health care needs of the people using the services are detailed in their individuals’ health care plans, which were presented in a pictorial format, and staff has guidance in relation to the level of support required, if any. Risk assessments are detailed and to include information about personal care, personal hygiene, medication, challenging behaviour, and day care activities. Staff and the people who use the service had good working relationships. This was supported through the observations made during the interactions, the people said; they enjoyed living at the home. Records viewed suggested people who used the service received personal support in the way they preferred and most were encouraged to maximise their independence. Each Byron Court DS0000068342.V367116.R01.S.doc Version 5.2 Page 15 person who used the service had a key worker, who they were each able to identify and those people who used the service that were spoken with, said they were happy with the support from them. The people using the service said they were not restricted and continued living their lifestyle of their choosing. The home had made arrangements for the people to maintain contact with family and friends. The people who live at the home have their privacy and dignity respected. For example 1 person who wanted to watch a DVD in her bedroom with her friend, was allowed to do so, at the same time, the staff to knocked if she needed help. Care plans detailed emergency contacts and health care professionals involved in their care. However, 1 person’s health care plan, a section on skin was left blank. This person had sensitive skin and whenever he is anxious he rubs his skin and now has a small wound on the right arm. This was brought to the attention of the registered manager post this inspection, which said, she would discuss this with the key worker who has the responsibility. The records showed people had regular appointments with the general practitioner, dentist psychologist, and opticians. Trained staff administers medication, staff training records, and staff spoken to have confirmed this. The staff on duty demonstrated a good understanding of the medication, and the importance of having the medication on time. People said they do receive their medication on time. Medication is stored in a locked cabinet with the medication records. The medication for two people using the service was checked, which was consistent with the medication records. The staff administering the medication have followed PRN medication guidelines, as and when they administer PRN medicine. Byron Court DS0000068342.V367116.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 and 23 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. Staff are trained and people who use the service their interests are protected by procedures and practices. EVIDENCE: The complaints procedure was available. The people using the services indicated that they were informed of the process how to make a complaint or express concerns about the provision of care provided at the service. A person said, if, “I am not happy, I just speak with the manager or my key worker”. The service has had 2 complaints received since the previous inspection and has resolved within 28 days time limit. This was supported by the information provided prior to the inspection. We have not received any concerns, complaints, or allegations about the service. The service had arranged for staff training on safeguarding, the staff on duty, demonstrated an adequate awareness of their role, responsibility, and procedures they are required to follow in relation to any allegation or suspicion of abuse. Staff were confident to whistle-blow poor on bad practice and confirmed that the registered manager is available should any concerns arise. The people using the service can choose to manage their own money if they are able to do so. Records of money transaction were maintained. Byron Court DS0000068342.V367116.R01.S.doc Version 5.2 Page 17 The staff member on duty described the process for recording and handling of money for people using services, which appeared inadequate. For example, the money transaction records and the balances were checked for 2 people, and found that 1 person cash balance was less by £10/- enquiries made suggested that the person had taken out £10/- to buy birthday present/card however, this was not recorded. Another person, cash balance was less by 10p; the staff was not able to provide any information on how this has happened. This was discussed with the registered manager; on her return from the leave, post this inspection. The registered manager had said that every week she undertakes checks and for this week because she was on leave, checks could not be carried out. She further said that she would revisit the staff guidelines for people’s money management and inform all the staff to follow the new guidelines, which ensures the money, is protected. The registered manager had sent in a copy of the guidelines to us on the 03/07/08. Byron Court DS0000068342.V367116.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 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. People who use the service live in a warm, clean and a homely environment. However, further development was needed to improve individuals rooms and communal area. EVIDENCE: The home was clean and tidy without any offensive odours and in appearance that suits the lifestyle of the people living there. The lounge/dining room decorated and furnished with domestic furniture that compliments the décor. There is good lighting throughout the home. Individual bedrooms were personalised to suit the choice and taste of the people who use the service. The bedrooms are appropriately furnished and include personal objects as well. One person showed us his bedroom, which had been personalised that reflected his interests. Byron Court DS0000068342.V367116.R01.S.doc Version 5.2 Page 19 The people who use the service appeared to be at ease in the home with the staff on duty, choosing to sit in the lounge or going to their bedroom. Information received from the registered manager prior to the inspection stated that the home has a rolling programme of maintenance and decoration of the bedrooms and communal areas. However, 1 person has been making repeated request for his room to be decorated since 03/12/07 and this has not been actioned yet, this person said ‘ I am fed up waiting for my room to be decorated’. Also, the ground floor small lounge roof, there was a small patch that appeared to be caused from leaking bathroom of the same person. The staff spoken to further confirmed this and reported that the maintenance person has been informed. This was also brought to the attention of the registered manager post this inspection, which has assured us that she would follow up on this. The hot water temperature checks that were carried out did not show how frequently each outlet was checked. This was discussed with the registered manager post this inspection and who agreed to arrange weekly hot water temperature checks of all points and records maintained. Further, the hot water temperature check that was carried out on 22/06/08-recorded 48degree Celsius for kitchen sink hand basin. Which was 4 degrees Celsius over and above the required temperature and there was no evidence as to what action has been taken to rectify this. The information received prior to the inspection from the registered manager stated that the premises electrical circuits, portable electrical equipment, fire detection and equipment heating and gas appliances cheeks have been carried out as required. Byron Court DS0000068342.V367116.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, 33, 34, 35 and 36 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The people who use the service are protected by staff recruitment procedures, training, and supervision. EVIDENCE: The interaction of staff with the people using the service was good; there was good rapport, both verbal and non-verbal communication was used. The key worker was aware of the needs of the person’s routines and how best to communicate with them. On a random sample, 2 staff recruitment records were seen and found that, staff appointed upon receipt of an application, interview, two satisfactory references, POVA, and Criminal Records Bureau (CRB) check. However, 1 staff reference were not made available, this was discussed with the deputy manager who was coordinating the inspection, even he was not able to locate on this inspection. This was further discussed with the registered manager post this inspection, who had informed that all the staff profiles were in a separate Byron Court DS0000068342.V367116.R01.S.doc Version 5.2 Page 21 folder in the office which the deputy manager was not aware and was not able to show on the inspection. Staff training records showed that staff have received induction training, safeguarding, moving, and handling, epilepsy, medication, health & safety, food hygiene, and first aid. This was supported by staff spoken to, which identified varied training, which they had undertaken. The information provided prior to the inspection by the registered manager showed that, of the total 14 staff only 6 have got NVQ level 2 or above qualification and 4 staff are working towards NVQ level 2. The service had maintained appropriate staff deployment ratio based upon the needs of the people who use this service. Staff on duty, confirmed they received supervision. In the staff supervision, concerns raised by staff are addressed in the best possible way, which benefits the people using the service. A scheduled staff meeting was observed, the meeting was chaired by the deputy manager and the meeting had an inclusive atmosphere, views were sought of all the participants and possible solutions explored regarding the concerns raised. However, there was no participation of the night staff in the staff meeting, this was brought to the attention of the deputy manager and the registered manager post this inspection, who said, she would explore ways and means to encourage night staff for their participation in the staff meeting for the benefit of self and people who live at the home as well. Byron Court DS0000068342.V367116.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 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The home has good quality assurance systems and procedures that enable the management to run a well managed home, to promote the quality of life of the people who use the service. EVIDENCE: The service has a registered manager. The registered manager though not available on the inspection, discussion with the staff on duty and the people who live at the home, the registered manager appeared to have developed good working relations with the staff and the people who use the service. Byron Court DS0000068342.V367116.R01.S.doc Version 5.2 Page 23 The various care documents seen on this inspection confirmed that there are clear roles and responsibilities in relation to the management of the home and staffing. However, the staff on duty was not able to locate and provide copy of statement of purpose, some of staff recruitment related information and also the staff have not recorded until this inspection that £10/- was taken out by a person. Staff meetings were held, to discuss people’s assessed needs and care delivery, to ensure people who use the service their assessed needs and staff training needs were being met. However, night staff participation needs to be arranged (for details please refer staffing, concerns complaints and protection outcome group of this report). The staff spoken to were confident that registered manager would be available if there was an emergency. Information received from the registered manager prior to this inspection stated that, all policies and procedures are updated, reviewed, and shared with the staff. As part of the quality assurance system and procedure the service had monthly coordinator reports, people who use the service their meetings, monthly staff meetings and regulation 26 visits, to ensure that the people living at the service their quality of life goals both short term and long term, were reviewed and appropriate efforts were made to achieve them. The premises, health and safety checks and risk assessments were carried out, for example on 21/05/08 fire and tumble dryer were reviewed. These checks help in identifying any concerns to the premises and to action them on time. However, 1 persons’ bedroom decoration and a patch on the roof of a small lounge repair are outstanding (for details please refer environment outcome group of this report). The people using services, spoken to confirm that, they are encouraged to express themselves about the running of the home, what improvements are made in relation to their accommodation, décor and they can speak with staff at anytime. 1 person said ‘ I am very involved with the running of the home’. Byron Court DS0000068342.V367116.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 2 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 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 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 2 X 3 3 X 3 X X 3 X Byron Court DS0000068342.V367116.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 YA24 Regulation 13 (4) (a) Requirement The registered manager must ensure that the individual and communal premises repair and maintenance work is carried out on time, to the satisfaction of the people living at home. Timescale for action 24/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA5 YA6 Good Practice Recommendations The registered manager should ensure that the people’s contract are completed with necessary details and signed. The registered manager should ensure that support plans and relevant care documents are in an appropriate format for people with communication need to understand. The registered manager should ensure that the people or their representatives were engaged in the care planning and review process, to understand and agree with the contents. The registered manager should ensure that all sections of DS0000068342.V367116.R01.S.doc Version 5.2 Page 26 3. YA7 4. YA19 Byron Court the health action plan including skin are completed. 5. YA23 The registered manager should ensure to have appropriate guideline for people’s money management and that the staff follows them to ensure the people’s money is protected. The registered manager should ensure that when hot temperature overshoots the required levels, action are taken and documented. The registered manager should find ways to have the participation of the night staff in the staff meetings for the benefit of self and people that live at the home as well. 6. 7. YA24 YA33 Byron Court DS0000068342.V367116.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE 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 Byron Court DS0000068342.V367116.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. 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