Inspection on 01/05/07 for Derriads

This inspection was carried out on 1st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Derriads 21/01/09

Derriads 16/07/08

Derriads 27/06/06

Derriads 06/12/05

Derriads 16/06/05

Derriads 27/01/05

Derriads 15/09/04

Derriads 24/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Derriads Respite Care Home 70 Derriads Lane Chippenham Wiltshire SN14 0QL Lead Inspector Alyson Fairweather Key Unannounced Inspection 1st May 2007 11:30 Derriads DS0000032436.V332251.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 Derriads DS0000032436.V332251.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. Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derriads Address Respite Care Home 70 Derriads Lane Chippenham Wiltshire SN14 0QL 01249 652814 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) Wiltshire County Council Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2006 Brief Description of the Service: Derriads is an extended bungalow situated in a quiet residential area on the outskirts of Chippenham. The home provides respite care for up to four service users at a time, who have severe physical and learning disabilities. The home is owned and managed by Wiltshire County Council. The manager and staff team also run Meadow Lodge, which is part of the Chippenham Respite Service. There is 24-hour staff cover to provide support for service users. Derriads is an attractive home, with a large lounge and comfortable furnishings. There is a separate dining room, a kitchen and two bathrooms, one with an assisted bath. There are four single bedrooms, all with wash hand basins and ceiling tracks for hoists. To the rear of the house is a large, secluded garden which is accessible to the service users, with aromatic plants and attractive features. Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in May, when four service users were staying. Four members of staff were spoken to, and one family returned our written questionnaire on behalf of their relative. Derriads has a new manager in post, although he is still to be registered with the Commission for Social Care Inspection. He is currently responsible for the day to day running of both Chippenham respite services, and is supported by senior staff in both homes. Various documents and files were examined, including care plans, risk assessments, health and safety procedures, staff files and medication records. Fees vary from £63.95 to £98.60 per week for a respite stay at Derriads. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: There are good assessment processes in place to help decide if the needs of a prospective service user can be met. Referrals come from a Care Manager who will provide the service with a recently completed Community Care Assessment and any other relevant information. Following this, a visit will be arranged for the person, along with their Care Manager and/or any other appropriate carer, family member, friend or advocate. After that other visits are arranged so that the person can meet with other service users and staff. The next stage would be for the new service user to have an overnight stay. A Service User Guide is given to every potential service user, and is available in pictorial format. The family who responded to the questionnaire felt that they had had enough information about Derriads prior to admission. The people who have respite care at Derriads are supported to take part in lots of activities. The service user who replied to our questionnaire said they could choose what they liked to do at night and weekends, and all four service users who were staying that day had been out at their different day services and came home in the late afternoon. Music is popular with many of the service users and some attend the local Gateway disco. Some people also attend the local Phab club, as well as visit the local pubs, cafes and shops. Some of the activities people like to do indoors are puzzles, board games and watching DVDs and television. One relative who wrote to us said: “The staff are always kind and friendly to my son”. Derriads DS0000032436.V332251.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. Derriads DS0000032436.V332251.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 Derriads DS0000032436.V332251.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 and 2 Prospective clients and families are given information leaflets so that they can choose whether or not they wish to use the service. All service users have their individual needs assessed before they arrive, so that staff know how best to support them. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: At the last two inspections the home was asked to ensure that an up-to-date statement of purpose and service user guide was available. This has been actioned by the manager, and the home now has a comprehensive Statement of Purpose and Service User Guide which give an overview of the service which will be provided. This is given to every potential service user, and also gives details of the organisation’s complaints procedure. The booklets are available in pictorial format. The family who responded to the questionnaire felt that they had had enough information about Derriads prior to admission. Referrals come from the prospective service users’ Care Manager who will provide the service with a recently completed Community Care Assessment and any other relevant information, in order to initially identify whether the service is appropriate for and able to meet the needs of the individual. Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 9 Following this, if it initially appears that they are able to offer a service, a visit will be arranged for the person, along with their Care Manager and/or any other appropriate carer, family member, friend or advocate. If successful, another visit will be arranged in order that the individual can join existing service users for a meal and to spend time socialising and interacting with current service users and members of the staff team. The next stage would be for the new service user to have an overnight stay then gradually build up to longer periods of respite. This process is very flexible and can be tailored to meet the needs of the individual. Derriads DS0000032436.V332251.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 Care plans mainly reflected the needs and personal goals of service users, who are supported to make decisions about their own lives. They are supported to take risks where appropriate, and encouraged to be as independent as possible, although some risk assessments had not been updated. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A great deal of work has gone into improving service users’ support plans, which include details of any personal care needs, medical and physical health, mental health needs, mobility and communication skills. The support plans also highlight people’s likes and dislikes, and what activities they like to take part in. Staff record residents’ activities well as their general wellbeing on a daily basis. Support plans are reviewed regularly, but can also be added to if there are any changes in the person’s situation. Manual handling assessments were in place for those service users who need them, and behavioural guidelines were also in place. Any restriction to stop self-harming behaviour is recorded in Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 11 the care plans, and guidelines on how to manage this are on the individual’s file. Several of the service users have transferred to Derriads from Sonas House for their respite care since the latter closed down. Much of the information on file came from there, and one file was seen to have an old epilepsy profile dated November 2005. It may be that there has been no change to the management of the person’s epilepsy, but the manager has been asked to make sure that a new, up-to-date profile is completed. It was noted that much of the paperwork used is headed Sonas House. It is recommended that this is updated to reflect the fact that Derriads is the service now offering respite care. Service users are supported to make decisions about their own lives with guidance from the staff. Service users’ families usually help them to manage their money. Money brought in differs with each service user, depending on what day services or activities they wish to pursue. Receipts are kept when any purchase is made with or for a service user. Risk assessments had been done for each service user and these included things such as mobility, bathing and travelling, and ways of minimising risks were identified. Staff place great emphasis on encouraging service users to be as independent as possible, while trying to minimise any risk to their safety. However, the risk assessment for one service user who had transferred from Sonas House was dated 1999 and related to risks about leaving doors unlocked, and another old one related to the person’s epilepsy. Another risk assessment from Sonas House related to the “heat seeking” of one service user, who liked to be close to radiators. This also had not been updated. As each house is very different, it is important for all risks to service users to be freshly assessed and ways of minimising any potential danger should be recorded. The manager has therefore been asked to ensure that all risk assessments are reviewed and updated. Derriads DS0000032436.V332251.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 Social and leisure activities are varied and tailored to individual need, and use facilities offered by the local community. Service users can have as much or as little contact with family and friends as they wish, and are supported to do so by staff. They are offered a healthy diet, with their preferences taken into account. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: As Derriads caters for respite service users, many people already have outside activities which they enjoy, and they are supported to continue with these. The service user who replied to our questionnaire said they could choose what they liked to do at night and weekends, and all four service users who were staying that day had been out at their different day services and came home in the late afternoon. Activities are usually recorded in a person’s care plan. One service user liked to have a pub-lunch in Lacock and to go out for a drive to Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 13 Melksham. Another person likes visiting garden centres and water features. Music is popular with many of the service users and some attend the local Gateway disco. Some people also attend the local Phab club, as well as visit the local pubs, cafes and shops. Some of the activities people like to do indoors are puzzles, board games, watching DVDs and TV and listening to music. Friendships both inside and outside the home are encouraged, and staff support links between service users and their family and friends, although the frequency of contact varies depending on the individual circumstances. Because Derriads offers respite care to families, some do not choose to visit at that time. Service users are free to visit friends outside the house at any time, and can entertain and choose to see who they like either in the privacy of their own bedrooms or in the communal areas available. One relative who wrote to us said: “The staff are always kind and friendly to my son”. Service users can choose when to be alone or in company, and when not to join in an activity. They have unrestricted access to the home and grounds, and can come and go as they please. Daily routines are flexible, with people choosing what they want to do when they return from day services. The menu supplied in the home is varied and nutritious, and is centred round the likes of the people staying in the home on a daily basis. Breakfast usually consists of cereal and toast, and lunch can be a cooked meal for those who are at home, or a packed lunch for those who go out during the day. The main meal of the day is at supper-time, and is usually cooked by staff, as the level of need of the service users means that cooking can be difficult for them. There was a good supply of fresh fruit and vegetables in the home, and juices and yoghurts were also available. Staff have records of the food likes and dislikes of all service users, and of any feeding support necessary. One service user was seen to have a mealtime routine on file which said that they should have a high-fat diet as they were trying to gain weight. Staff were clearly aware of how to thicken drinks and what kind of foods should be offered. Derriads DS0000032436.V332251.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): Personal care needs of service users are written in care plans so that they can receive support in the way they need and prefer. Their emotional health needs are met, although their physical needs are compromised, and they are at risk of harm because of the lack of appropriate bedside equipment. The home’s medication policies and staff good practice in administration and recording ensure that service users are safe when their medication needs are being met. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: All service users have support plans for any personal care required. The information contained in them is gathered from the initial community care assessment and the home’s own assessment and staff knowledge of the service users. People have guidelines in place which say how they like to be helped to get washed and dressed, assisted with food and helped to and from bed. At the moment, service users are not able to be helped in the bath, as it has been deemed a health and safety risk. The bath is currently only able to be accessed from one side, and service users could be at risk of banging into the wall. Staff also are at risk because of poor manual handling space. All the Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 15 families of the people who attend Derriads for respite care have been informed that the bath is not able to be used. It is recommended that the plans for changing the bathroom are put into place as soon as possible. If the families live locally, the person’s own general practitioner (GP) is used, and the home’s local GPs are used for those who live further afield. Medical professionals are seen as and when required. This varies according to the needs of individuals and the situations arising while having respite care. One service user is supported to access chiropody and dental appointments by staff and the community nurse when on respite at Derriads. The home has good links with the local learning disability teams, which enables them to get help in any crisis periods which may arise. Derriads has various adaptations and pieces of equipment in place to help with service users’ physical needs, including hoists and ramps. At previous inspections it was noted that some service users used bed rails, and staff had been asked to ensure that reviews were sought for those service users so that there could be multidisciplinary team agreement for their use. This had been done, although assessments carried out by health professionals had shown that these bed rails were dangerous, and could lead to people being trapped in them. The manager reported that the home had researched the various types of bed rails and knew which ones would be appropriate. He went on to state that there was some difficulty in deciding whether the funding for these was paid for by the local authority or by health. This situation has been on-going for some time, and is unacceptable when the potential safety of service users is at risk. The manager has therefore been asked to ensure that any resident in need of bed rails has the correct type fitted. The home has a policy in place for all medication, and all staff have medication training when they first start work. The storage and recording of medicines in Derriads is good. Medication is kept in a designated room and is kept in a locked cupboard in this room. Medication support is recorded on a Medication Administration Record (MAR) and when checked this was seen to be accurate. Specific training has been carried out for the administration of Midazolam which is a medication to assist service users who may need emergency treatment in the event of a seizure. Records of medicines received, administered and disposed of, including those sent out with service users to day centres were examined, and seen to be in order. There had been one incident where a service user had jerked the arm of a staff member and the liquid medication had been spilled. Registered homes are obliged to notify the CSCI when any incident occurs relating to medication, and this had not been done on this occasion, so the manager has been asked to ensure that all staff are aware of their responsibility in this area. Derriads DS0000032436.V332251.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 Service users feel their views are listened to and acted on. The policies and procedures the home has in place try to ensure that residents are safeguarded from abuse and harm, although training for staff in the protection of vulnerable adults would enable them to be more aware of abuse issues. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home has a complaints procedure which outlines the steps to take if there are any complaints, and all service users get a copy of this. It also gives details of how service users and families can contact the Commission for Social Care Inspection (CSCI). A complaints book is kept in the office, and it was noted that five formal complaints had been recorded there. These complaints were all seen to have been dealt with appropriately. No complaints have been received about the home by CSCI. One family member who was helping their relative to write to us said that they knew how to make a complaint and who they would talk to if they were not happy. The home has copies of the “No Secrets” document, as well as the organisational policy and procedure on responding to allegations of abuse. All staff members are encouraged to report any incidences of poor practice, and a “Whistle Blowing” procedure is available. There are guidelines in place for the management of challenging behaviour. All staff have annual vulnerable adults training, and new members of staff have induction training in this area. Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 17 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 Service users live in a homely, comfortable and safe environment which is clean and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Derriads is an attractive bungalow, with level access throughout the home, and a ramp up to the front door. Care staff look after the general household cleaning and chores. The lounge is a large, comfortable room, and has some sensory equipment in one corner. It is fitted with an overhead hoisting system and has a TV, DVD, video player and stereo system for communal use. The kitchen is bright, and cheerful, with a stable type door to the kitchen, so that service users can be safe whilst staff are occupied cooking. The bedrooms are fully furnished with TV and CD players and each bedroom has a washbasin. There is a very attractive garden, suitable for wheelchair access, with a seating area under shade and a swing for guests to use. Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 18 The dining room window frames have been replaced, meaning that service users now can relax in a warm room with no condensation on the windows. The badly stained carpet has now been replaced, meaning that service users who come in from home for respite care have a clean, attractive environment when they visit. One relative who wrote to us said: “It’s homely, and always fresh and clean”. One staff member has responsibility for the infection control measures in the home, and ensures that the rest of the staff team are aware of any new policies which are introduced. Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 19 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 Service users are supported by competent and qualified staff, and their needs met by appropriately trained staff. They are protected by the home’s recruitment policies, although some references were missing from staff files. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: There are usually three staff on-duty in the mornings and evenings and two staff overnight. Waking night staff are available according to the assessed needs of individuals. All new staff receive induction training, and have also started using the Learning Disability Award Framework (LDAF) to assist their training, which means that the needs of service users with learning disabilities will be more fully understood. There are currently six staff members who have completed their NVQ Level 3 and one who has completed their NVQ Level 2. One has also completed the Work Place Assessor award. Various observations were made of staff interactions with service users. All staff were seen to be patient and good humoured, taking time to talk with Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 20 residents and encourage them to express their thoughts and opinions. The relatives who responded to our questionnaire said they were satisfied with the overall care provided, and that their family member was always treated well by staff. Staff recruitment is assisted by Wiltshire County Council’s human resources department. All staff have Criminal Records Bureau (CRB) checks and are checked against the Protection of Vulnerable Adults (POVA) register. Two written references and a medical declaration are also required. The staff files looked at mostly contained the appropriate documentation. However, one file had only one written reference on file and another had evidence which showed that two references had been taken verbally, with no written corroboration. References are one way in which an employer can be sure that the person is of good character, and to fail to have this in writing could mean that service users are at risk of being cared for by someone unsuitable. The manager has been asked to ensure that each staff member’s file contains two written references from now on. Training records showed that staff had received training in food hygiene, Positive Response, Safeguarding Adults, epilepsy awareness, emergency first aid and manual handling. Most staff have had Wiltshire County Council’s training course “Valuing People”. Future training planned includes conflict resolution, first aid, food hygiene and fire safety. Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 21 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 Residents benefit from a well run home. They know that their views underpin the monitoring and review of care practice. The home’s policies and procedures, and the health and safety checks carried out, mean that residents live in a safe environment. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home’s manager, Mr Mark Pearson, was appointed last year. He is yet to be registered with the Commission for Social Care Inspection (CSCI). Mark has been a registered manager in residential homes for fourteen years. He has also worked with children & young adults with autism, Aspergers Syndrome & challenging behaviours. Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 22 A quality assurance questionnaire has been devised by the home for service users and their families, and they are asked if they enjoyed their stay and what might be improved on. Wiltshire County Council also conducts regular internal audits, and a senior manager visits the home every month to meet with service users and check on various records. A “Friends of Derriads and Meadow Lodge” action group has been active for several years. The group consists of families of service users who meet regularly to discuss service issues and organise fundraising events. Staff are invited to the group’s meetings in order to share information and exchange ideas. There were good health & safety records in place. Records show that staff have been trained in areas relating to health and safety, such as fire safety, manual handling and prevention of spread of infection. The fridge and freezer temperatures are recorded daily and there are various weekly and monthly checks done to make sure the home is safe. The home’s hoists, tracking systems and other equipment are serviced on a regular contractual basis. Fire equipment checks were done in January 2007, the latest fire drill was March 2007, emergency lighting was checked January 2007 and the hoists were checked in October 2006. There were no electricity or gas certificates present to show that these items had been checked, although the manager reported that he had asked for copies of these. He has been asked to ensure that these are sent to the home. Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 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 3 33 X 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 2 X 3 X 3 X X 2 x Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 2 3 4 Standard YA6 YA9 YA19 YA20 Regulation 15 (2) (b) 13 (4) (c) 13 (4) (c) 37 Requirement An up-to-date epilepsy profile must be completed for the specified person. All risk assessments must be reviewed and updated as necessary. All service users who need the use of bedrails must have the correct type fitted. Staff must all be aware of their obligation to notify CSCI of any incident affecting the wellbeing of a service user. All staff files must contain two written references. Evidence of fire and gas checks must be kept in the home. Timescale for action 15/05/07 01/06/07 01/06/07 01/06/07 5 6 YA34 YA42 Schedule 2 Para 5 13 (4) (a) 01/07/07 01/06/07 Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 25 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 YA6 YA18 Good Practice Recommendations Care plans and risk assessments should clearly state the name of Derriads respite care service. The plans to update the bathroom should be put into place as soon as possible so that people will be able to have a bath if they want to. Derriads DS0000032436.V332251.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Derriads DS0000032436.V332251.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. 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. 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