Inspection on 10/09/07 for Evimiz

This inspection was carried out on 10th September 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 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evimiz 08/09/08

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 Evimiz 155 Fairview Road Cheltenham Gloucestershire GL52 2EX Lead Inspector Mrs Helen James Key Unannounced Inspection 10th September 2007 09:15 Evimiz DS0000068544.V345560.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 Evimiz DS0000068544.V345560.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. Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evimiz Address 155 Fairview Road Cheltenham Gloucestershire GL52 2EX 01242 701779 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) Evimiz Care Ltd Mr David Paul Dodwell Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - (Code PC) to male service users whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is 3. This is a new service that was registered in March 2007. Date of last inspection Brief Description of the Service: Evimiz Care Ltd is a converted domestic dwelling in the centre of the Fairview area of Cheltenham. It is a terraced house that provides residential accommodation for up to three male adults with Learning Disabilities/Autistic Spectrum Disorder from eighteen to sixty-five. The house has accommodation on the ground and first floor. There are three single bedrooms with use of a communal bathroom with bath, hand basin, and toilet and shower cubicle. There are no en-suite facilities in the home. On the ground floor is a communal lounge, dining room and kitchen. Off the kitchen is the laundry area, a toilet and access to the courtyard garden. The Managers/Staff office/sleep-in room is located in the basement. All the accommodation has been registered to meet current environmental standards. To the front of the property is the pavement and on-road parking. The courtyard garden is to the rear of the property and is screened by a fence with access from the street via a locked gate, all of which is adequately maintained at the present time. The fee range for the home is from £1033 to £1220 per week dependent on needs. Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Unannounced inspection is the first inspection for this service since it was registered in March 2007. The inspection took place over six hours on one day in September 2007 and was completed by one inspector. Twenty-six Care Standards for Adults (18-65) including all twenty-two Key standards were assessed on this occasion. Of these none exceeded the standard and two met the standard, twenty-one almost met and three did not meet the standard. The reason for many being almost met at this inspection is the fact that many standards could not be tested/ evidenced, as the home has no track record of providing a service to date. When the Annual Quality Assurance Assessment was returned prior to the inspection there had been no people living at the home. The home has only recently admitted a person to the service (2 days ago). The one person living at the home was at the Day Centre during the visit, and having moved in two days before the inspection, they were only just beginning the period of settling in after being cared for at home, so were not seen on this occasion. Time during the inspection was spent speaking with the Registered Manager Mr David Dodwell. Most of the information was gained via discussion with the Manager and examination of the limited documentation that was in place. The inspector spent time examining the care documentation for the new resident and a range of other records including medication records, staff files and training information as well as health and safety systems. A tour of the premises was also made. What the service does well: We were unable to test the Key Standards fully on the day of the inspection as the individual person living at the home had only been at the home for two days, so there was no track record of the management of the service, staff or the care of the individual. But on discussion with and through examining documentation many issues were highlighted that needed to be addressed for the quality rating of the service to improve. The Manager is keen to meet all the requirements of this report and to adhere to guidance to ensure that the service meets the needs of individuals and that people living at the home have an excellent quality of life. The staff team appear committed to the philosophy of ensuring that people living at the home engage in a range of social and recreational activities that are age appropriate, improve their quality of life and integrate them in the local community. The Manager has the intention to support his team well by ensuring tight recruitment practice, team meetings, supervision, appraisal and training/developmental opportunities. Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: As we were unable to test the Key Standards fully on the day of the inspection issues were highlighted with the Manager from examination of documentation and in discussion. These must all be addressed immediately now the service is providing care to people and employing staff. All records relating to the care of the individual living at the service must be complete and fully available to staff to allow them to maintain the individuals’ health, safety and welfare. The Registered Person must ensure that policies and procedures relating to administration of medication are implemented and that staff complete accredited training. The Registered Person must ensure that recruitment and employment practice complies with regulation 19 to ensure protection of people using the service. The Manager must evidence through records staff induction, training, development, supervision and appraisal. The and and and Registered Person must ensure that all records relating to health, safety welfare and protection of people living in the service, and for the effective efficient running of the business are in place, maintained and up to date accurate. The Registered Person must ensure that documented auditing tools for the service are in place that examine quality and effectiveness of systems in the home and hence contribute to the Quality Assurance system for the home. 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. Evimiz DS0000068544.V345560.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 Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3,4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that each prospective person is fully assessed prior to admission and on admission, to ensure that all their specific care needs can be met by the Home. EVIDENCE: The statement of purpose and the service users guide are available in the home. These could be displayed in the foyer of the home with general information. The Manager reports that this information is given to individuals/ families/representatives on enquiry/admission. The Manager needs to be converting these into formats that can be understood by the users of the service. The Manager is required to add to the service user guide about the Fire procedures and the alarm testing in the home. Individuals are assessed prior to and on admission and sometimes on a number of occasions, they are also encouraged to visit the home and stay for the day/night/weekend. Documentation needs to be in place for these visits. The admission is planned over a period of months. Once admitted a continual assessment of the person is made and after a month a full review is called and again at three months and then yearly with all relevant parties concerned with the individuals care. Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 9 The home must ensure as far as possible that the placing Authorities review placements yearly and that this is recorded in the care file. Copies of all assessment documentation will be in the persons individual care file; these will provide specific details of care need, relevant risk assessments, activity/Lifestyle programmes, next of kin and general information. The assessment will be done in conjunction with the Community Learning Disabilities Team (CLDT), Social Workers and the families with input from individuals who are to be or being cared for where this is possible. There has been one admission to the home since the home was registered in March 2007. Much of the evidence for this inspection was gained through discussion with the Manager and examining documentation. People will have contracts (none seen at the visit) but it is the relative or Social Services who deal with this in the main and not the person residing at the home, due to the fact that they are unable to deal with this themselves. The Manager must ensure that the contract contains all the required details and is compliant with Office of Fair Trading Standards. No views had been sought from relatives/representatives, staff, Social workers, District Nurse, GP etc, as there were no people living at the home when the AQAA was returned. One person started living at the home two days prior to the inspection. Evimiz DS0000068544.V345560.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 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning system will involve the individual and their family to ensure that all members of staff have a clear understanding of the person-centred care each person to lead a full and rewarding life. Care plans will ensure people are treated with respect and dignity and facilitated to live as independent a life as possible within their own limitations. EVIDENCE: We were unable to test these standards as the individual person living at the home had not be at the home long enough for there to be a full documented care plan in place. All we were able to see was the record of care from a daily report. It is essential that assessment documentation is put in place immediately and is added to over the period of the initial assessment. No information in any detail relating to care was available. Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 11 The Manager reported that he is in the process of putting the documentation in place. He said that people would be assessed and reassessed as their personal needs change and the plan would be to review care monthly, there must be evidence of these reviews. The Manager must also ensure that the placing authority provides a written careplan prior to admission. It is also essential that the person living at the home and their family / representative sign up to the care plan and risk assessments and that the Manager can evidence this. Evimiz DS0000068544.V345560.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 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People will be able to participate in age, peer and culturally appropriate activities through engagement in social activities of their choice and liking within the local community. Individual will be offered a healthy diet and be able to participate in the buying and preparation if they choose. EVIDENCE: We were unable to test these standards as the individual person living at the home had only been at the home for two days. Whilst there has been a period of introductions and familiarisation this has not enabled the Manager to fully assess the wishes and wants in relation to living a full life and developing new skills/interests for the individual. Hence this is not documented yet and the individual is continuing his routine prior to admission. All we were able to see was the record of care from a daily report and what he had been doing. Today he is at the day centre. Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 13 It is essential that this information is assessed and documented, albeit it is provisional information but it could begin with what is already known. What is written in the statement of purpose is very positive and acknowledges that there are many options for different interests, activities, education and social engagement within the wider community in the town setting, conducive to the age of the client group. Menus were not available for examination and the Manager reported that the home is to implement a daily food diary. The people living at the home will be involved in the daily meal planning and be involved if they choose, in going shopping and cooking with the care staff. The kitchen is clean and tidy and a documented cleaning schedule is in place that includes temperatures of the fridge and freezer. The Manager is to implement a record of core cooking temperatures for appropriate foods and is to buy a food probe to ensure food is cooked appropriately. The Manager and staff must maintain comprehensive records in line with ‘Safer Food Safer Business’ guidelines. Environmental Health is to visit on the 20th September 2007. All staff have Basic Food Hygiene certificates, which are current. Evimiz DS0000068544.V345560.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 & 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The personal needs of people living at the home will be supported in the way they prefer and will be met through good multi disciplinary working to ensure all healthcare needs are fully met. People will be protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: The home has been given information relating to the daily routine of the individual who is now living at the home, from his family. This is assisting in settling the individual into the home and is also a baseline to further assessment of need for the individual. The Manager reports that too much change too quickly for this individual could lead to him not settling at the home. People at the home are to be registered with the local GP and this is being arranged for the individual who has just be admitted to the home. The local chemist will then supply the home with the MDS system for medication. Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 15 At present the home is using medication dispensed by the previous GP and records are being maintained. The Manager is to arrange ASSET accredited medication training for all staff and to ensure that policies and procedures relating to medication practice are in place at the home. Evimiz DS0000068544.V345560.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 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People will be confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems are in place that safeguard people from possible harm or abuse. EVIDENCE: This is a new service so to date no complaints have been received. The Complaint procedure is explicit in the Statement of purpose. The Manager is in the process of devising and implementing complaint and compliment forms for the service. It is recommended that these are available and accessible to people coming in and out of the front door. There was evidence that staff who have been recruited have had training in Adult Protection in 2006 but we would require them to be updated in light of the new procedures and guidance for the County. The Manager must implement a visitor book at the entrance to the home and ensure visitors to the home sign into the home, for fire and security purposes. Evimiz DS0000068544.V345560.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical environment provides for the individual requirements of people living at the home. People live in a home that is safe, clean and wellmaintained environment that partially complies with infection control standards. EVIDENCE: A walk around the environment was conducted and all rooms were inspected. Bedrooms are being decorated to individual tastes when people are admitted. The individuals’ room seen at inspection was personalised with belongings, personal sound and vision equipment, photographs and pictures, giving a homely feel. The communal areas were pleasantly decorated and appeared comfortable. The Manager said that individuals had brought their own furniture and possessions with them and had been involved in the colour schemes etc in their rooms. Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 18 Equipment for special needs will be provided as the need is identified. All the people living at the home will need to be able to walk upstairs as there is no lift or stair lift at the present time. At the time of the inspection the home was clean and tidy. There was evidence that staff are provided with personal protective equipment that is accessible throughout the home. The laundry room was clean and had washable wall and floor surfaces and hand washing facilities. Domestic washing and drying machines are available. All staff have a responsibility for overseeing the laundry and cleaning within the home, although this is not explicit in the generic support worker job description and this needs to be addressed. Records of cleaning throughout the home are recommended for auditing purposes. Hazardous products are locked away and data sheets/risk assessments are kept in the cleaning cupboard in the home, although all are domestic products. The Manager needs to give some thought to how toiletries are kept for individuals in the communal bathroom, once there are three people living at the home. In the communal bathroom and kitchen there were no hand washing and hand drying facilities for staff to prevent cross-infection this must be addressed. All staff require infection control training. There is a handyman who deals with ‘day-to-day’ maintenance issues. The following maintenance issues were identified during the inspection that require addressing: • In the dining room the sideboard has a glass panel in the door. This poses a potential hazard, as it does not appear to be safety glass and is not protected. • The registration certificate is required to be displayed. • The chain restrictors on the low level window in the rear bedroom need to be replaced and proper restrictors put on. • A maintenance book needs to be implemented to evidence work in progress/ completed. The Manager reports that the exterior still requires painting and the front low wall is to be replaced with low railings, and the front garden is to be tidied up. Evimiz DS0000068544.V345560.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 & 35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Peoples’ needs must be met by a competent staff team, who have access to a training programmes that ensures that staff have knowledge about the diverse needs of people living at the home. People at the present time are not protected by robust recruitment practice at the home and this needs addressing urgently. EVIDENCE: Inspection information seen indicated that the Manager and two care staff work at the home and three staff are to work on a bank basis. All have been appointed since the home was registered in March 2007. The recruitment practice was not acceptable and did not comply with Regulation 19 for the following reasons: Of the two staff that have begun work both have • No application form, • Neither have had a Povafirst or Criminal Records Bureau Check (CRB) back yet, (although one had both of these returned to the Manager during the inspection), Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 20 • One has no reference from the previous employer. Neither of these staff can be left alone on shift with the person living at the home due to these reasons and this was explained to the Manager at the inspection. Whilst the Manager may have worked with these individuals in the past and they have CRB’s from previous employers these are not transportable and recruitment practice under the Care Homes Regulations must be fully compliant with Regulation 19. The Manager agreed that he would be working until the CRB/POVA issue had been addressed. The issue of employing family members was also raised and it was reiterated that it is essential that their employment is fully compliant with Regulation 19 as well. If this issue is not addressed the Commission will take enforcement action in the form of a formal notice. Staff have had a verbal induction to the home but this is not evidenced and formal induction must be undertaken. The Manager confirmed that he would be implementing the Skills for Care Induction documentation. The home will be staffed by one member of care staff from 7am until 9-30pm and at night from 9-30pm until 7am by one waking staff member. The manager will be on–call at all times. This staffing will be suitable at the present time to meet the needs of the individual living at the home. Evidence was seen via training records that staff recruited have had previous mandatory training but Evimiz Care is required to ensure training is pertinent to the new environment they are working in and that training is ongoing. All staff require mandatory training and specific training for the client group to be cared for in the home, such as first aid, management of epilepsy, challenging behaviour training and crisis intervention. Training must be well supported by regular supervision sessions (six times a year) and yearly appraisals and these must be recorded to evidence the content of the supervision and staff development. The Manager is devising a training matrix. Of the two members of care staff one has a National Vocational Training (NVQ) Level 3 in health and social care (adults). Evimiz DS0000068544.V345560.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, 40 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service need to be safeguarded by good management that actively promotes their best interests offering them choice, respecting their wishes and keeping them safe whilst safeguarding their health, safety and welfare. EVIDENCE: The Manager has an Open University qualification in ‘Managing Health and Social Care’ but has no formal qualification in Care. Therefore the Manager is required to do an NVQ level 4 in Care or equivalent as soon as possible. The Manager is actively pursuing his continuing professional development by participation in local training and attending training courses to develop his skills and abilities. Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 22 We were unable to test these standards fully as the individual person living at the home has only been at the home for two days and so there is no track record of the management of the service. But several issues were highlighted with the Manager from examination of documentation and in discussion that require addressing immediately now the service is providing care to people and employing staff. The following Policies and Procedures must be fully in place now: - death of service user, accidents/incidents, emergencies and crises, first aid, Management of service users money, valuable and financial affairs, missing service users, record keeping, recruitment and employment, sexuality and relationships, moving and handling, infection control, access to files, code of conduct, confidentiality, Control, storage, disposal, recording and administration of medicines and any others that the Manager deems as necessary, which are not yet in place. Policies and procedures needs to be printed out and placed in a file for all staff to read and sign to say they have read them. Guidelines for care practices within the home need to be devised. Also maintenance of equipment checks and all portable appliances checks must be undertaken and evidence be available. All portable appliances bought into the home by residents must be tested. Indemnity Liability insurance is in place and the certificate was seen. All the weekly, monthly and yearly safety checks on appliances and systems in the home need to be implemented and documented evidence must be available for inspection. All the Fire system testing and training must be implemented and recorded as defined in the Fire Risk Assessment. The Fire Risk assessment is in place and is documented but gives no evidence of how frequently and why the systems are to be tested this must be addressed. The Manager must send evidence of the boiler-commissioning certificate into the Commission. Water temperatures must be monitored at outlets around the home and recorded to evidence this to demonstrate safe outlet temperatures are being maintained. The hot water system must be tested yearly for Legionella. The Manager must put in place systems to assess the standards of care being provided and audits of the systems within the home as part of the Quality Assurance System in the home. This must include surveys of internal and external people using the service. From this information the Manager will produce a Homes Audit/Quality Report that indicates the measures that will be taken to improve the service or address issues that have been raised. Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 23 This should then be available to people living in the home and their relatives/social workers/doctors etc. Evimiz DS0000068544.V345560.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 2 2 3 3 2 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 2 X 2 X Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 YA1 Regulation 4(2). Requirement Timescale for action 31/12/07 2. 3. YA1 YA6 Schedule 1(11) 15 4. YA7 15(2c) The statement of Purpose and the Service Users Guide must be in a format that can be understood by the people using the service. The Manager is required to add 30/11/07 to the service user guide the Fire procedures and the alarm testing The Manager must ensure that: - 30/11/07 • Assessment documentation is available immediately an individual is admitted. • A basic careplan is in place from admission and added to over the period of the period of the initial assessment. • That the Placing Authority provides the home with a Careplan prior to admission. The Manager must demonstrate 30/11/07 involvement of the service user/ their representative in the development of the care plan and risk assessments and that this is evidenced. DS0000068544.V345560.R01.S.doc Version 5.2 Evimiz Page 26 5. YA11 16(2n) 6. YA17 16 (2g, h, i & j) 7. YA20 13(1& 2) 8. YA23 Schedule 4(17) 13(6) 23(2) 9. 10. YA23 YA24 All individuals must have recorded evidence of activities/social opportunities that they participate in. The Manager must: • Buy a food probe to ensure food is cooked appropriately. • Record of core cooking temperatures for the appropriate foods. • Implement a daily food diary to be implemented for all living at the home. The Manager is to ensure that: • People living at the home are registered with the local GP. • Medication systems are implemented in the home. • Policies and Procedures relating to medication practice are put in place. • Medication training for all staff is arranged. The Manager must implement a visitor book at the entrance to the home for fire and security purposes. All staff must receive Abuse awareness /adult protection training update. The following environmental issues need addressing: • The Registration certificate is required to be displayed. • In the dining room the sideboard has a glass panel in the door needs to be protected or removed. • The chain restrictors on the rear bedroom lowlevel window need to be replaced and proper restrictors put on. • Storage for toiletries in DS0000068544.V345560.R01.S.doc 30/11/07 30/11/07 30/11/07 30/11/07 31/12/07 30/11/07 Evimiz Version 5.2 Page 27 11. YA30 13(3) 12. YA34 19 & Schedule 2 13. YA35 18(1c) 14. 15. YA35 YA39 19 24 (1-3) the communal bathroom needs to be addressed. The following infection control issues must be addressed: • Hand washing and hand drying facilities in the bathroom and kitchen for staff to prevent crossinfection. • All staff must undertake training in infection control. The Manager must ensure that recruitment procedures are followed for all staff and employment files contain all the required information in line with Regulation 19. All staff require mandatory training and specific training for the client group to be cared for in the home, such as management of epilepsy and challenging behaviour training. The Manager must ensure that a documented Induction is implemented for all staff. The Registered Person must produce an annual quality assurance report to evidence the review of the quality systems in the home. This must include stakeholders’ views and future developments in the home. The policy and procedure on Management of personal monies in the home needs to be devised and implemented. The Registered Person must ensure that all the Policies and procedures to ensure the health, safety, welfare and protection of people using and working in the home are implemented, as identified in the body of the report. 31/12/07 30/11/07 31/12/07 30/11/07 30/03/08 16. YA41 16(2l) 30/11/07 17. YA41 21(1) 30/11/07 Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 28 18. 19. YA37 10(3) 23(2 & 4) YA42 The Manager is required to do an NVQ level 4 in Care or equivalent. The following safety checks must be implemented and recorded: • Fire Alarm system testing in line with the homes’ Fire Risk Assessment. • Portable Appliance Testing for all electrical appliances. • Water temperatures must be monitored at outlets around the home. • The water must be tested yearly for Legionella. • The boiler-commissioning certificate must be sent into the Commission. The Fire Risk Assessment document must be amended to include the frequency of the testing of the system within the home. 30/03/08 30/11/07 20. YA42 23(2 & 4) 30/11/07 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 YA5 YA22 Good Practice Recommendations The Manager must ensure that the contract contains all the required details and is compliant with Office of Fair Trading Standards. The Manager to devise and implement complaint and compliment forms for the service and make these available and accessible to people coming in and out of the front door. A maintenance book needs to be implemented to evidence work in progress/ completed The generic support worker job description needs to be explicit about the responsibility staff have for domestic and catering responsibilities. Policies and procedures must be printed out and placed in DS0000068544.V345560.R01.S.doc Version 5.2 Page 29 3. 4. 5. Evimiz YA24 YA30 YA40 a file for all staff to read and sign to say they have read them. Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Regional Office 4th Floor Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Evimiz DS0000068544.V345560.R01.S.doc Version 5.2 Page 31 - 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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