Inspection on 03/07/07 for Combe House

This inspection was carried out on 3rd July 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 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

Combe House 12/07/06

Combe House 31/10/05

Combe House 23/06/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Combe House Castle Road Horsell Woking Surrey GU21 4ET Lead Inspector Helen Dickens Unannounced Inspection 03 July 2007 10:45 DS0000062711.V344968.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 DS0000062711.V344968.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. DS0000062711.V344968.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Combe House Address Castle Road Horsell Woking Surrey GU21 4ET 01483 755997 01483 773681 val.coomber@brookhurstcare.co.uk 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) Brookhurst Care Limited Valerie Jean Coomber Care Home 7 Category(ies) of Learning disability (7) registration, with number of places DS0000062711.V344968.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 2006 Brief Description of the Service: Combe House is situated in a quiet residential area of Horsell Village, a short distance from Woking town centre. It is a new property, which is tastefully developed and blends in well with the surrounding properties. This home provides care and accommodation for young adults with a learning disability. The accommodation consists of seven individual en suite bedrooms. There is no lift access to the first floor. Communal areas consist of two bathrooms, two dining areas, a conservatory and separate sitting room, and easily accessible kitchen and laundry room. The dining room, kitchen and conservatory have doors leading directly onto a large terrace and medium sized secure back garden. The home has a good-sized area for parking at the front of the building. The fees at the home range from £1,350.00 to £1,800 per person per week. DS0000062711.V344968.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over 7 hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The Deputy Manager represented the establishment. A partial tour of the premises took place. The inspector spoke briefly to two residents, and had more in depth conversations with two others; the fifth resident was on holiday. All staff members on duty, and the owner who called in during the afternoon, were also spoken with briefly. Four ‘comment cards’ returned to CSCI, and the Annual Quality Assurance Assessment (AQAA), which was very thoroughly completed by the manager, were also used in writing this report. Two resident’s care plans and a number of other documents and files, including two staff files, as well as risk assessments and maintenance records, were examined during the day. The Commission for Social Care Inspection would like to thank the residents, deputy manager and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: Combe House offers a very homely environment for residents with the standard of maintenance and gardening being very high. Resident’s spoken to liked their rooms which are very individually furnished, some with wall paintings and other memorabilia reflecting their personal hobbies and interests. The communal areas are bright and spacious with the new conservatory now offering even more light and space at the back of the property. Resident’s independence and autonomy is promoted and the report contains a number of examples of this, including one resident who was supported to take part in a sponsored walk recently, and has subsequently raised £300 for charity. Relatives think well of the home and a number of positive comments were noted on satisfaction questionnaires and compliments letters to the home. One wrote ‘I continue to be delighted with the care and stimulation’ and another said they were happy with the care and ‘..the effort made to accommodate his interests. He is always happy to return to Combe House after a visit with us.’ DS0000062711.V344968.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. DS0000062711.V344968.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 DS0000062711.V344968.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The needs and aspirations of prospective residents are assessed prior to them being admitted to the home. EVIDENCE: Two resident’s pre-admission assessments were checked and found to contain a good overview of their personal, health and social care needs. One had the Care Programme Approach care plan and both had assessments from members of the multi-disciplinary team including the occupational therapist, nursing assessments, and the care manager’s community care assessment. In addition to the assessments from external professionals, the home carries out their own assessments and these were noted on the two files sampled. At the last inspection there was a Requirement to ensure all residents had a copy of their contract with the home on file. On the day of this inspection, one was missing and this was thought to be because the resident sometimes looks after their own file and the document may have been taken out. The deputy manager was asked to locate the contract and it was faxed to CSCI the following day. DS0000062711.V344968.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): 6,7,8 and 9 Resident’s assessed and changing needs are reflected in their care plans, and they are enabled to make decisions about their lives with assistance as needed. Residents are consulted on the daily activities of the home and are supported to take risks as part of an independent lifestyle. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two resident’s files were sampled and care plans were drawn up to reflect the pre-admission assessments and their changing needs. Both had been regularly reviewed. The plans covered all aspects of daily living including support with personal and health care needs, communication, mobility and orientation. Strategies were in place to deal with challenging behaviours focusing on positive behaviours and abilities. There was particular attention paid to the preferred hobbies and activities of residents. DS0000062711.V344968.R01.S.doc Version 5.2 Page 10 Those residents spoken with confirmed their social needs were being met. For example one resident who was very fit and enjoyed exercise was pleased to tell the inspector he had been supported to take part in a sponsored walk the previous weekend and had raised £300 for charity. Residents at Combe House are encouraged to make decisions about their lives and there were many instances throughout the day when residents were given choices. There are no set times for meals for example, except to fit in with outside activities such as school or day care. There are two dining areas and residents can choose where they wish to eat. On the day of the inspection the owner returned with the weekly shopping, including cakes for residents and staff. Residents chose their cake and went off to eat it – one came to join the inspector and the deputy manager and discussed his activities and aspects of his care plan whilst he had his tea. One staff member was taking a resident out to the shops earlier in the day and the timing was noted to be according to when the resident was ready to go out, not for the convenience of the staff member. Decisions made with residents on issues such as managing their finances, how they like their personal care delivered, and the support they would like with activities of daily living, are recorded on their files. The staff encourage residents to participate in the life of the home. They are encouraged to assist with household chores and the deputy manager said all residents now bring their laundry down to the laundry room and help to put it in the machine. One resident’s file sampled showed that he made drinks and sandwiches in the kitchen. On the day of the inspection one resident was going out to buy birthday gifts for another resident whose birthday was the following day. The format for resident’s meetings has changed and instead of holding a house meeting, which was not very successful, individual resident’s meetings are held monthly with each resident. The standard format allows residents to comment on their life in the home, any concerns they have, or any changes they would like to make. The home also carries out user satisfaction surveys and has translated a number of documents into more accessible formats to help encourage resident’s involvement. Residents are encouraged to take risks as part of an independent lifestyle. Risks are assessed prior to admission and specialist advice taken as appropriate. Risk management strategies are in place and those risk assessments sampled had identified potential hazards and minimised these. One resident who enjoyed their ‘resident’s choice’ hour (i.e. to listen music, watch TV, or have some private space etc) did not feel safe being isolated in their room due to a medical condition. They were supported to have this session by a member of staff sitting outside the room for the duration of the activity. The home needs to consider some additional risk assessments including the short drop of 8-10 inches from the edge of the new patio, and radiators which DS0000062711.V344968.R01.S.doc Version 5.2 Page 11 do not have covers. This is highlighted under Standard 42 and a Requirement will be made in this regard. DS0000062711.V344968.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 the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents at Combe House are encouraged to take part in appropriate activities and be part of the local community. They are encouraged to maintain family and friendship links and are treated respectfully by staff. Combe House offers resident’s a healthy diet and flexible mealtimes. EVIDENCE: The residents at Combe House are encouraged to take part in further education and fulfilling activities. One attends school and several others are involved in further education. Care plans demonstrate that resident’s interests and accomplishments are taken into account when planning for activities, and goals are set for residents to work towards. Courses currently being taken by residents include media studies, photography, drama, cookery and art. The deputy manager said that the staff are working hard to finalise college DS0000062711.V344968.R01.S.doc Version 5.2 Page 13 placements for residents for next year but these are being restricted due to cutbacks in further education; the criteria for admissions has been changed which means a number of residents will be excluded from some courses. Residents are encouraged to be part of the local community and they use shops, restaurants, pubs and leisure facilities. Some use the Woking library computers, and visit the local cinema and theatre. Staff spend time with residents outside the home not just during the normal 9-5 hours, but also in the evenings and weekends. One resident described how he had been out to a Thai restaurant the night before and had enjoyed a Thai curry. The home is in keeping with the other properties in the road in that the garden and outside of the property is exceptionally well kept and Combe House does not look like a care home from the outside. Family links are encouraged and staff were knowledgeable on family relationships. Returned questionnaires to the home, and compliments letters received since the last inspection, showed that family members were satisfied with the care offered at this home. Comments such as ‘Thank you for your help and understanding’ and ‘…We’d like to thank you all for everything you’ve done to improve his life so immensely’ were typical. Residents at this home are treated respectfully by staff. They can choose to be alone or in company, and the size and layout of the property with two dining areas, a large lounge, and the new conservatory allows residents plenty of room indoors if they want some private space. There is also a large very well kept back garden and patio with seating which is available for residents to enjoy. There were no instances during the inspection of staff speaking exclusively with each other and excluding residents. However, there were many examples of staff including residents in what was happening and stopping their own conversations in order to involve a resident who had joined them. Residents are offered a healthy diet and on the day of the inspection there were good supplies of fresh fruit, vegetables and salad even before the owner arrived with fresh supplies. Strategies are in place to encourage residents to eat healthy food including a ‘shiny stickers’ chart in one dining room were a resident is awarded stickers for each portion of fruit, vegetables and salad eaten. Residents are involved in choosing the menus and assist with some shopping, preparation of drinks and snacks, and clearing up afterwards. The last environmental health officer’s report showed no requirements needed to be made in relation to the kitchen. All staff have done the food handling and hygiene course and the nutritional needs of residents are recorded on their care plans. DS0000062711.V344968.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 Residents are offered personal support in the way they prefer and require and their health needs are met. Arrangements for the administration of medication are good. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s care plans outline their wishes regarding how they would like to be supported with personal care. Staff were observed to deal discreetly with resident’s personal care needs and this support was provided in private. One resident had guidelines translated into widget and symbols and these were posted in places were he could refer to them if he needed to. His name did not appear on the guidelines to protect his privacy. Residents were dressed very individually and their appearance reflected their personality. Residents are supported to manage their own healthcare and their files show the health action planning format is used, with set goals, and dates when these have been completed. There are good records of specialist interventions DS0000062711.V344968.R01.S.doc Version 5.2 Page 15 including speech and language assessments, psychiatric assessments, and referrals to the psychologist. Resident’s files contained information on healthy lifestyle options, nutritional needs, and medication guidelines. This home is working towards accreditation by the National Autistic Society for provision of care to people with autism. The deputy manager said the process can take up to 18 months and Combe House have been working on this for 8 months so far. When they believe they have reached the required standards they will be inspected by the Society and then listed as one of the preferred providers for this type of care. Arrangements for the administration of medication are good. There is a medication policy in place and all staff are trained to give medication; the next in-house refresher course is booked for July 12th. It was noted that the induction booklet for new staff contained a very detailed medication competency assessment test at the back. The home has regular pharmacy inspections by the community pharmacist, the last one being in April of this year. The report noted that staff training was up to date, the medication administration records were properly completed and there was excellent stock control. The guidelines on ‘as required’ medication have now been reviewed as requested at the last CSCI inspection. Copies were on resident’s files and the deputy manager was asked to put copies with their medication administration records; this was done immediately. The arrangements for keeping the medication keys were discussed with the deputy manager and the owner of the home. Advice was sought from the CSCI pharmacist who concluded that the home had considered all the options and their current arrangements were satisfactory. DS0000062711.V344968.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 the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s complaints would be taken seriously and they are protected from abuse. EVIDENCE: There have been no complaints at the home since the last inspection and none received at CSCI. There is a complaints procedure in place and residents have a regular opportunity to raise any concerns at their one-to-one monthly meeting. Two residents were spoken to at length on the day of the inspection and neither had any complaints; both were happy with the service they were receiving and with the home itself. On the comment cards returned to CSCI and on questionnaires sampled at the home, two relatives and one resident said they did not know how to make a complaint. The deputy manager was asked to consider reminding all stakeholders about the arrangements for making a complaint. The home has the latest copy of the local Surrey procedures for safeguarding vulnerable adults and their own in-house policy. Staff had refresher training following the Requirement made at the last inspection. As part of their induction, new staff read and sign to say they have understood the safeguarding procedure. The deputy manager said that safeguarding matters are covered on the first day of the induction for new staff though this was not on the Day One induction list when checked by the inspector; the deputy DS0000062711.V344968.R01.S.doc Version 5.2 Page 17 manager said she would ensure this was added. There has been one safeguarding issue received about this home since the last inspection. This has now been dealt with and the matter closed. The owner was asked to think about the wording of the in-house procedure and in particular the use of the word ‘serious’ in the policy. She suggested removing this word completely to avoid the implication that only serious allegations of abuse need to be reported, which was not the intention. Resident’s finances are safeguarded by the arrangements in place at the home. All residents have families who assist them but there is an option to keep small amounts of money at the home to enable residents to have access to money for their day-to-day needs, for example spending money when they go out. Two resident’s cash boxes were checked and matched the written records of resident’s expenditure. All receipts are kept and the finance manager checks the records on a monthly basis. Only the shift leader has the keys to the secure cabinet, and the monies are checked at staff handover. DS0000062711.V344968.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 the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a very homely and comfortable environment, which is clean and hygienic throughout. EVIDENCE: A partial tour of the premises took place and this included all the communal areas and three resident’s bedrooms. The home is well maintained with very well kept gardens to the front and rear or the property. The furnishings and fittings are of good quality and domestic in character. The new conservatory adds light and space to the sitting room and dining room, and provides an additional pleasant place for residents to enjoy. Bedrooms were very individually decorated and furnished, reflecting resident’s hobbies and interests. One resident who had recently had his room decorated said he had chosen the colours himself. DS0000062711.V344968.R01.S.doc Version 5.2 Page 19 There were some minor decorative matters which needed attention including damage to paint in two areas of the sitting room; a bath panel which needed painting and the bath mat may need to be replaced; and some staining had appeared on the kitchen ceiling. All these matters were already known to the owner and on the maintenance list to be dealt with. The home has a dedicated maintenance man who also looks after the garden. The home is generally clean and hygienic with good hand washing facilities throughout. There is an infection control policy and good arrangements in place for dealing with laundry. The laundry room is clean and tidy and there are individual baskets to keep resident’s clothes separate. The deputy manager said all residents bring their own laundry down and some help to put it in the machine. There was a small area in the home which had a slight odour and the owner was arranging to have the floor covering replaced. One quote had already been received and she said they would be making the arrangements as soon as possible. The day after the inspection a second quote was obtained and the manager confirmed the floor covering would be replaced by the end of July. DS0000062711.V344968.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): 32,34,35 and 36 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent staff who understand their needs well. Recruitment practices are good and there have been improvements in arrangements for staff training and supervision. EVIDENCE: Staff at Combe House were observed to be approachable, and residents were seen to turn to them for support and advice throughout the inspection. All staff interacted well with residents and the communication needs of residents were clearly documented on their individual care plans. Staff were knowledgeable about the management strategies for dealing with resident’s challenging behaviour and for promoting their independence. It was noted that the home has a very low rate of staff sickness and the manger noted on the AQAA that loss of time through staff sickness was less than 1 for the calendar year 2006. DS0000062711.V344968.R01.S.doc Version 5.2 Page 21 Though the manager and deputy manager have passed the registered manager’s award, only two of the remaining care staff have completed their NVQ Level 2 in care. The target set down in Standard 32 is that a minimum of 50 of care staff should hold this qualification. The home are dealing with this shortfall and now 7 of the remaining 11 care staff are working towards their NVQ Level 2, and some of these are already over half way through. Two staff recruitment files were sampled during the inspection. Arrangements for recruitment are generally good and application forms, evidence of photographic identification, and two written references were on both files. Criminal Records Bureau checks had been carried out, including checks against the POVA list to ensure staff had not previously been found unsuitable to work with vulnerable adults. One file sampled did not have a completely full employment history and the manager followed this up, faxing through the information about the gap to CSCI. Training arrangements have improved since the last inspection and a training development plan is being drawn up using Skills for Care advisers; this includes a skills analysis for each member of the staff team. Each staff member had their certificates on file for the training courses they have completed and the home is compiling a central list of training to show, at a glance, who has had what training, and when refresher courses are due. There is a structured induction programme in place including a one-day orientation, followed by a workbook covering all aspects of the workers roles and responsibilities. There is a detailed medication administration competency assessment at the back of each induction book. All staff at this home have had (or are currently booked for) the LDAF induction programme which lasts for 6 days. All staff also do equal opportunities training. Supervision arrangements have also improved since the last inspection and the staff files checked showed staff were on course to receive the six sessions per year as set down in Standard 36. DS0000062711.V344968.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 and 42 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home and there are good quality assurance processes in place. The health, safety and welfare of residents is promoted and protected though further work is needed to ensure there are sufficient risk assessments in place. EVIDENCE: The registered manager has sufficient management experience to run the home and has completed the Registered Manager’s Award. The deputy manager has also completed this qualification. DS0000062711.V344968.R01.S.doc Version 5.2 Page 23 Residents benefit from the leadership and management approach of the home, which creates an open and inclusive atmosphere. The home has an equal opportunities policy and all staff do equality and diversity training. Staff are knowledgeable on promoting the rights and independence of residents; some policies and documents are translated into more user-friendly formats; and the home and grounds are fully accessible to the current group of residents. There are a number of quality assurance measures in place including a business improvement plan, monthly Regulation 26 visits, and one-to-one resident’s meetings. There are returned questionnaires from residents and their relatives in the quality assurance file at the home, and the AQAA document had been completed very thoroughly, giving a good overview of the home’s achievements and forthcoming plans. The home also has monthly health and safety checks, monthly checks of resident’s finances by the finance officer, and monthly analysis of any incidents and accidents. Complaints are also monitored though none have been received for some time. There are a number of measures in place to ensure the health and safety of residents and staff including monthly health and safety checks, and monitoring of water temperatures. The home’s current insurance certificate and CSCI registration certificate were displayed in the hallway. Some safety certificates were sampled including the fire extinguisher checks (November 2006); electrical appliance testing certificate (January 2007); and the gas safety check (April 07). The environmental health officer visited in May 2006 and no problems were found; it was noted that all staff were trained and there were sufficient hazard analysis measures in place. The home de-scales shower heads each month and monitors water temperatures, but it was not clear whether a legionella risk assessment has been carried out as recommended for care homes by the Health and Safety Executive (HSE). Advice should be sought either from the local environmental health department, or from the HSE and all monitoring of water systems should be clearly documented. In addition, a risk assessment on the step down from the patio to the garden, and on the radiators which do not have safety covers, should be carried out. DS0000062711.V344968.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 2 X DS0000062711.V344968.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 YA42 Regulation 13 (4)(a)(b)(c) Requirement Risk assessments must be carried out, and any necessary actions taken, in relation to the step down from the patio into the garden, and the radiators which do not have safety covers. Timescale for action 09/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA23 YA42 Good Practice Recommendations The first day induction list should identify safeguarding vulnerable adults as an issue to be highlighted to all new staff. Advice should be taken, and a risk assessment carried out, regarding the monitoring of water systems within the home in order to prevent legionella. DS0000062711.V344968.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000062711.V344968.R01.S.doc Version 5.2 Page 27 - 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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