Inspection on 22/06/05 for Dysons Wood House

This inspection was carried out on 22nd June 2005.

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

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

Other inspections for this house

Dysons Wood House 07/12/06

Dysons Wood House 22/11/05

Dysons Wood House 01/02/05

Dysons Wood House 17/08/04

Dysons Wood House 26/02/04

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

CARE HOME ADULTS 18-65 Dysons Wood House Dysons Wood Tokers Green Caversham RG4 9EY Lead Inspector Julian Griffiths Announced 22 June 2005 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 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 Stationary 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. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dysons Wood House Address Dysons Wood, Tokers Green, Caversham, RG4 9EY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01189 724553 01189 723479 Dysons Wood Trust Jose Rodriguez Care Home 15 Category(ies) of LD registration, with number of places Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1 February 2005 Brief Description of the Service: Dysons Wood House is a residential centre registered for 15 young adults with autistic spectrum disorders. There are two units providing accommodation on one large site with extensive grounds and a sensory room. The service is located in a rural area of South Oxfordshire and near to the facilities of Reading. Transport is available to access community resources and for service users to attend a day centre which is managed by the provider, the Disabilities Trust. Due to the nature and diversity of autistic spectrum disorders, Dysons Wood House provides a service for young adults with challenging behaviours and complex needs. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector was in the home from 10am until 5.15pm on the day of the inspection. Much of the inspection was spent looking at records and documents, but service users and staff were listened to and observed and most of the premises was looked at. The next inspection, which will be unannounced, will look at the parts of the service and standards that were not covered. The inspector’s conclusion was that Dyson’s Wood House was well managed and provided a high quality and specialist service for people with complex and challenging needs. The open and positive way in which the home approaches inspection is commendable. What the service does well: The home is continually seeking to improve and develop its services and opens itself up to scrutiny by the National Autistic Society and the British Institute of Learning Disability. Staffing levels are good, often exceeding the minimum required levels, recruitment processes are sound and the commitment to staff training outstanding. Service users’ bedrooms were seen to be highly individual according to needs, and indicative of the commendable work that the home undertakes to enable individuals to move on from physically destructive behaviours. Care planning is thorough and comprehensive, enabling service users’ needs and wishes to be met. The home has a very strong and appropriate emphasis on enabling effective communication between staff and service users. The home’s employment of psychologists and other therapeutic staff is very beneficial to service users. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 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. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 A thorough assessment is carried out by staff before any prospective service user is admitted. As part of this, staff have access to other relevant information about the person. EVIDENCE: The inspector saw the pre-admission assessment records relating to three service users. The documentation indicated a thorough and detailed process. One assessment was recorded as having been carried out by members of the home’s management team and an assistant psychologist. Another did not indicate who had carried it out. All such assessments should indicate who carried them out. Also seen was assessment documentation from a service user’s previous placement, which had been provided by a social worker. One service user had been admitted under the Care Programme Approach (CPA). The documentation was not inspected on this occasion. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 7 Service users have clear and well-produced written plans which set out in detail their needs and wishes. All elements of care plans need to be signed and dated so that they can be effectively and regularly reviewed. EVIDENCE: A sample of a service user’s care plan was inspected. It included personal details including all the information required to be kept by law, a contract, a service user guide set out in symbol form and an equal opportunities statement. A section entitled “This is me” included support needs, communication needs and likes and dislikes. There was a Behaviour Support Plan, a section entitled “How to Communicate with Me”, and an absence policy. The home produces a separate absence policy for each service user who is likely to absent themselves from the home without prior notification. It is based on their specific individual needs. An information pack is kept with reference to each of these service users and which is given to the police should the service user be missing. The home’s approach to this is to be commended. The plan included an activities plan and associated guidance, risk assessments and review and specialist reports. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 10 Discussion with assistant psychologists indicated that they make a substantial contribution to the care planning, monitoring and review processes. A care plan document was seen which set out the circumstances and manner in which a service user’s liberty might need to be physically restricted in order to safeguard his welfare. This document was unsigned and undated and no review dates were included so that its provenance was unclear. It is particularly important that such documents are signed, dated and regularly reviewed. The manager confirmed that this matter had been addressed by the day following the inspection, but it is recommended that an audit of all such documents take place to ensure that all meet the same standard. A staff member told the inspector that she could not think of an occasion when service users’ rights or decisions were overridden or restricted, but that non-physical redirection was used in some cases to promote service users’ welfare. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) No judgement was reached in respectof these outcomes as none of the standards in this section was assessed on this occasion. EVIDENCE: Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 The home ensures that service users have ready access to health care, which is provided by professionals in the community, and by specialists working for the Trust. Overall the home’s management of service users’ medication was satisfactory although some aspects of recording need to be improved. EVIDENCE: The inspector saw records in which service users’ visits to hospital, GP and dentist were recorded. The inspector noted in this record an entry stating that a service user had been offered, but declined, a ‘flu’ jab. A separate record of eye test appointments was seen. Also seen was a document, in symbol form, for a service user’s information explaining in detail a dental procedure. The home employs its own assistant psychologists who are psychology graduates with a special interest in learning disability who work very closely with staff and service users under the direction of a clinical psychologist. The home’s clinical team also includes an art therapist, a music therapist, a speech and language therapist and a psychiatrist. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 13 The inspector looked at the home’s medication management policies, inspected various medication records, inspected medication in storage and talked through the administration process with a staff member. The home’s medication policies and procedures were satisfactory, and storage in the main house was clean, well organised and secure. There was documentary and verbal evidence that staff were properly trained and that there was regular auditing of the systems by the community pharmacist. The home uses the Boots monitored dosage system. Some pharmacist’s labels and the corresponding entries on the administration record sheets stated only: “As directed by your doctor”, and no other instructions were available. The GP should be requested to write full instructions for dose and administration so that these are to hand when the medication is given to the service user. In any instance where this is not done the home must ensure that full instructions are available elsewhere for staff to refer to at the point of administration. Handwritten additions to administration records should be signed by the GP or staff member making the entry and documented in the service user’s records Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has a written complaints procedure which ensures that complaints are fully and promptly responded to. Presentation could be made clearer to potential complainants. The home needs to make sure that all service users’ families receive a copy of the procedure. The home has produced a complaints procedure in symbol form for use by service users. The home has a proper written procedure for dealing with allegations or suspicions of abuse of a vulnerable adult, of which staff are aware. EVIDENCE: The inspector saw the home’s written complaints procedure. A single document sets out the procedure for staff of the Trust who might receive complaints. The manager said that there was no separate document setting out what to do for potential complainants such as service users’ families. It was recommended that such a document be produced and sent out to families since two of the three respondents to the Commission’s pre-inspection survey said that they were unaware of the Trust’s complaints procedure. The home has a complaints procedure for service users which has been produced using symbols and which the inspector saw. The home’s complaints record was seen which recorded all required information and showed that complaints were dealt with swiftly and satisfactorily. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 15 The Oxfordshire County Council Codes of Practice for the Protection of Vulnerable Adults were not available in the home. The manager arranged for them to be obtained and agreed to audit the home’s own procedure to check for consistency with the codes. The home did, however, have a copy of the West Berkshire procedures for the protection of vulnerable adults. A staff member was able to tell the inspector how an allegation or suspicion would be responded to and records seen indicated that all staff had received instruction in this area. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 and 30. The fabric of the home is subjected to hard and continuous wear and tear so that a continuous effort is needed by the home to maintain an acceptable standard. It is to its credit that overall a good standard is achieved. Levels of furnishing vary according to the needs of different service users, some of whom will tolerate only minimal furnishing, and this is entirely appropriate. Every service user has his or her own bedroom, and some have en-suite facilities, although this is not appropriate for all. Service users are thus enabled to maintain privacy and personal space. EVIDENCE: The inspector visited most areas of the home. He did not visit all private bedrooms. All areas of the home that were seen by the inspector were clean. The home comprises the original old house and the Courtyard and Gables which are modern extensions. Communal areas were large and comfortable, carpeted and with a variety of seating and tables. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 17 The kitchen in the extension was accessible to service users and of a good domestic standard. The inspector saw service users being encouraged to use it. There were two comfortable lounges. Bedrooms were furnished individually and the interests of the individual occupants were much in evidence in the rooms seen. All bedrooms in the Courtyard and Gables were fitted with appropriate locks for which service users could hold their own key. A notice board displayed photos of the staff on duty, and each service user’s activity programme for the day in symbols. All rooms were labelled, either with a service user’s name in the case of private bedrooms, or pictorial symbols in the case of communal rooms. In the Courtyard a bathroom door lock was broken; the inspector was told that this had been reported to the handyman for repair. The hot water temperature at a bath tap was 47 degrees centigrade, slightly higher than the 41-45 degrees recommended, and should be monitored. Low surface temperature radiators were fitted throughout. In the old house the character of service users’ bedrooms varied widely, from one that was devoid of all furnishing except a bed, and had specially fitted washable floor and wall coverings appropriate to a service user’s needs, to a room full of personal possessions and very comfortably fitted out. Rooms at intermediate stages between these two were seen. It is to the home’s credit that it has enabled some service users, based upon their individual needs, to progress from rooms that were devoid of furniture and fittings to those with a more usual and comfortable standard. At the time of inspection only one service user in the old house had a key to his bedroom Some areas of the house were carpeted, others fitted with hard washable floor coverings. The landing floor was bare and awaiting a new carpet. The kitchen was kept secure and service users were only enabled to access it with staff supervision. Two WCs in the old house were seen to have no seats; a staff member said that service users would not tolerate them, and one WC had had the door removed for the same reason. This left sharp protruding hinges which the inspector considered to be a possible safety hazard if not removed. The manager was advised, and confirmed that they had been removed the day following the inspection. Bath hot water temperatures in the old house were found to be 51 degrees centigrade, which is significantly in excess of the recommended safe temperature. The day following the inspection the manager confirmed that this had been rectified. Most radiators in the old house are fitted with protective covers. One, in a bedroom, was not. The inspector was satisfied with the reasons for this and that there was no safety risk. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 18 The home employs two full time maintenance staff who also provide an on-call service. One of these staff is a qualified and properly equipped electrical appliance tester. Using symbols on a specially produced display, the home advises service users of maintenance that is taking place, with special emphasis on any activity that might be noisy or smelly or involve wet paint. The inspector saw a clean, well organised laundry, equipped to a commercial standard. Staff said that service users did their own laundry with staff support, and this was confirmed by a service user. The home is set in extensive grounds. Staff members said that this was a positive benefit to service users, and a service user said that it was one of the main reasons why he was so happy with the service. Some service users have outbuildings for their own use in which they can pursue their interests, and there is a polytunnel for horticultural work. A staff member expressed the view that more outside equipment, for example swings and climbing apparatus, would be of benefit. The manager said that this was being actively pursued. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36 The home is well staffed by a well organised and skilled team. The home is to be commended for its continuous and wide ranging programme of staff development and training which enables staff to work to a high standard. The home has had an over-reliance on agency staff to maintain staffing levels but recruitment of new staff was taking place to try and reduce this. EVIDENCE: Staff on duty were seen to be well organised and managed, with a designated shift leader, a handover and planning meeting at every shift change, and the responsibilities and duties of every staff member on shift allocated and recorded. Staff spoken to were aware of the limitations on the duties that could be carried out by agency staff. The GSCC Code of Conduct was seen to be displayed in the office in the main house and records seen indicated that every staff member had been given a copy. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 20 The manager stated that 25 of staff held NVQ Level 2 or above and that the home had staff qualified to assess at NVQ Level 4. Discussion with staff and observation of their practice indicated that they were accessible to, approachable by and comfortable with service users, and that they were able to communicate effectively with service users, both verbally and non-verbally. A service user told the inspector that staff were very empathetic and very good at sorting out problems. The manager stated that a minimum of seven staff members was required to be on duty throughout the day in order to support current service users. The staff duty rotas seen showed this number met and often exceeded with up to ten staff members on a shift. Staff and service users spoken to said that there were always enough staff on duty. Recruitment records relating to two staff members were inspected and found to be complete in all respects. Records seen and discussions with staff showed that the home has a comprehensive, wide-ranging and continuous programme of staff training for which it is to be commended. This ranges from initial induction, which a new staff member described as excellent, through the LDAF foundation training, NVQ, and two staff were undertaking a Birmingham University net based autism course. All basic health and safety training is included in the programme, as well as a great deal of autism specific input with a strong emphasis on communication and non-violent crisis intervention. The inspector was impressed with the facility with which some staff observed communicated verbally and non-verbally with service users. One staff member said that she had received more training in two years at the home than she had had in 12 years with the health service. Another said that the training programme had given him confidence and enabled him to overcome his initial apprehension in working with service users. Records seen and discussion with staff showed that all staff received regular individual supervision, at 4-6 week intervals, from a more senior colleague with the appropriate skills, for example the assistant psychologists received their supervision from a clinical psychologist. Supervision records seen showed that all aspects of staff responsibility were covered and recorded. Records of annual, formal, recorded staff appraisal were seen. Records showed that regular staff meetings were held. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 21 The manager stated that the home had used 330 agency staff shifts in the eight weeks prior to this inspection but that he was actively working to reduce this. He was in the process of recruiting more staff. Employed staff members spoken to told the inspector that they were satisfied with the quality of agency staff, but difficulties were sometimes caused by the limitations appropriately placed on the duties agency staff could undertake, for example they were not authorised to drive the home’s vehicles. Most of the agency staff used worked in the home over a period of time and so were able to get to know the service users and the home. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 The home is well managed, open to scrutiny and continually seeking to improve. The management of the home places a high priority on health and safety and is conscientious in seeking to maintain this in a challenging environment. EVIDENCE: The home opens itself up to external professional scrutiny, seeks and welcomes feedback from service users and their families and has an open and positive attitude to inspection. The service is accredited with the National Autistic Society, which requires an annual in-depth inspection by external NAS assessors. The inspector saw the NAS inspection documents and current accreditation certificate. Part of the process involved ascertaining the views of service users and their families. The home is currently working on a separate quality audit of outcomes with the British Institute of Learning Disability. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 23 There was evidence that a representative of the Trust had visited the home and reported to the Trust in writing on its conduct every month, as required by law. The inspector saw all the reports for the previous 12 months. The inspector saw records of monthly service user meetings, with between four and eight attendees, and that service users’ views were clearly expressed in these records. The dates of meetings were seen to be advertised on a notice board in the home. The home produces regular newsletters for staff and service users’ families, and is developing a feedback form to be incorporated in the families’ newsletter. Where it was possible, recommendations made by the inspector in the course of this inspection had been fully addressed by the time the inspector left the home. The manager confirmed that others had been addressed by the following day. Inspection of records and discussions with managers and staff showed that health and safety training was being carried out as required with systems in place to ensure staff attendance. Records were seen that indicated that equipment and infrastructure at the home were being safely maintained and that the home was complying with its obligations under health and safety legislation. The home has written health and safety policies which staff are required to read and work to, and a clear and comprehensive risk assessment process. The accident/incident record was seen which showed that these were being recorded and reported. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 4 3 3 x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score 3 3 3 3 4 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Dysons Wood House Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 4 x x 3 x H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 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 20 Regulation 13(2) Requirement In any instance where full instructions are not printed on the pharmacists label of a medication, the home must ensure that they are available elsewhere for staff to refer to at the point of administration. Handwritten additions to administration records should be signed by the GP or staff member making the entry and documented in the service user’s records. Timescale for action 31/07/05 2. 3. Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 22 Good Practice Recommendations That a separate complaints procedure document be produced and sent out to families. That the GP be requested to write full instructions for dose and administration of medicines, rather than As directed so that these are to hand when the medication is given to the service user. That an audit of all care plan documents specifying a restriction of a service users liberty take place to ensure that all are signed, dated and regularly reviewed. 2. 20 3. 6/7 Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Burgner House, Cascade Way Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: 0845 015 0120 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 Dysons Wood House H57-H08 S13079 Dysons Wood House V225044 220605 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!