Inspection on 27/06/06 for Faycroft

This inspection was carried out on 27th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Faycroft 09/05/07

Faycroft 10/11/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Faycroft New Street St Georges Telford Shropshire TF2 9AP Lead Inspector Rebecca Harrison Key Unannounced Inspection 27th June 2006 09:30 Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 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 Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 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. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Faycroft Address New Street St Georges Telford Shropshire TF2 9AP 01952 616515 01952 640995 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) Care Tech Community Services Limited Mrs Paula Johnson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2005 Brief Description of the Service: Faycroft is registered with the Commission for Social Care Inspection to provide accommodation and personal care for a maximum of six adults with learning disability. The home stands in its own grounds and is conveniently located in a residential area of St. Georges, Telford, close to local amenities and just a short journey from Telford Town Centre. CareTech Community Services Ltd is the provider and was registered with CSCI on 11.08.05. The responsible individual is Mr Stewart Wallace and the registered manager is Ms Ms Paula Johnson. Caretech’s philosophy is included in the Statement of Purpose for the home and states ‘CareTech and their staff work on the philosophy of enabling people to live as full a life as possible, supporting them in their daily activities and any identified long term plans. We recognise that all people with disabilities should be given due respect to their individuality enabling all to be fully involved in any decisions having an affect on their lifestyle commensurate to the level of their abilities and enabling people to maintain all their entitlement associated with citizenship’. The current fees charged per person range from £762.47 to £1606.72 per week. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started at 09.30 a.m. and lasted six hours. It was carried out by talking with three service users, the manager and the staff on duty, case tracking two service users, observing work practices, reviewing a number of records and a full tour of the home. 21 key National Minimum Standards for younger adults were assessed in addition to Standards 1,5,11 and 14 and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. It was not possible to assess key standard 2 on this occasion, as there have been no new admissions to the home. The service users, manager and staff on duty were welcoming and co-operated fully throughout the inspection. The purpose of this unannounced inspection was to review the progress made since the last inspection undertaken on 10th November 2005. One requirement and four recommendations were made as a result of the inspection. No complaints have been referred to the Commission for Social Care Inspection (CSCI) since the last inspection however a recent complaint has been received by the home and is currently being investigated. No referrals have been made adult protection procedures. What the service does well: What has improved since the last inspection? People living at the home are now provided with greater opportunities to get out into their local community and enjoy accessing leisure, college and social events. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 6 Daily records are now far more detailed. Vacant rooms have been redecorated in preparation for future admissions. There are no staff vacancies due to the recent appointment of two new staff. Service users are now in receipt of in-house six monthly reviews. The documentation seen was detailed and included agreed needs, desired outcomes and proposed actions. Quality Assurance Audits are regularly undertaken by the organisation and a detailed report of the findings forwarded to the team. The individual needs of a person of ethnic minority appear to be better met. A staff member provided good examples of how this is promoted in relation to diet, hair care and pictorial images displayed in her bedroom. Religious observance was also clearly documented in care records reviewed. 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. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 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 Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 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 the following standard(s): 1 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place to successfully accommodate an admission to the home. EVIDENCE: A Statement of Purpose and Service user Guide were submitted to CSCI for purposes of registration in 2005. No new service users have been admitted since the last inspection therefore it was not possible to assess key Standard 2 on this occasion. The home currently has two vacancies. The manager reported that three referrals have been received however she does not consider the service appropriate for two of the people referred. The manager has not yet had opportunity to undertake an assessment of the person very recently referred to the service. Signed contracts between the provider and service user were seen on the two service users files reviewed. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 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 the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care-planning systems are in place to adequately provide staff with the information they need to satisfactorily meet service users assessed needs. Service users are appropriately supported with decision-making making processes and enabled to take responsible risks within a risk-assessed framework. EVIDENCE: The care documentation of the two people case tracked was reviewed at length. Each service user has three files consisting of a support plan file, current file and a historical file. The support plan file is used daily and includes individual support requirements identifying assessed needs and includes clear information on ‘How I want staff to assist me and how I do not want staff to assist me’. The care documentation on both files was comprehensive and staff spoken with during the inspection confirmed that they are provided with sufficient information to appropriately support the individuals concerned. Person Centred Plans (PCP’s) have yet to be developed. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 10 In-house reviews have been undertaken on those case tracked and letters seen evidence that significant others had been invited to attend but only one letter of apology from a health professional was received. Review documentation was comprehensive and included agreed needs, desired outcomes and proposed actions. The manager reported that only one service user has been formally reviewed by their placing authority since the last inspection. An Individual Reactive Management Plan prepared by a Health professional from the local team was available on the file of one person case tracked which provides information for staff to support the individual positively and consistently. Due to two incidents that have occurred and changes in support requirements when out accessing the community, a Health professional attended a team meeting in April 2006 to provide staff with guidance and agreed to compile an Individual Reactive Management Plan to assist in the management of specific behaviours however the manager reported that she has not received this to date. Observation charts available evidence an increase of behaviours with five recorded incidents during June 2006. Behaviour observation records seen on the files of the two people case tracked indicate no physical intervention was used. The home has previously accessed the services of an independent advocate. The manager reported that the service was costly and people did not appear to benefit from the sessions. Each service user has an allocated key worker who advocates on behalf of the individuals they support in addition to formal ‘Talk Time’, which has recently been introduced to assist with decision-making processes. It was reported that the organisation has recently introduced a service user forum whereby one service user from each home meets with other representatives from homes across Shropshire and Birmingham. It was stated that such meetings are very successful with enabling service users to become more involved in decision-making processes within the organisation. Numerous risk assessments were seen on the two care files reviewed enabling people to take responsible risks. A risk assessment review log was seen in place and all assessments have been reviewed and updated since the last inspection. Generic risk assessments have been developed by the organisation and staff are required to individualise these. As reported in the last report the assessments refer to the client and therefore continue to lack a person centred approach. A comprehensive risk assessment to support service users on a holiday to Blackpool was seen and both the manager and area manager approved this. A very detailed holiday checklist was also completed prior to supporting people on holiday. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 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 the following standard(s): 11,12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with good opportunities for community presence and participation. Family links are maintained, rights and responsibilities promoted and people provided with a varied and balanced diet in accordance with their personal preferences. EVIDENCE: One of the people case tracked attends the local college three days per week and was out accessing college at the time of the inspection. Her desired goals were documented on the review documentation seen on file, which includes the desire of an employment opportunity. One staff member stated that the home could further develop the life skills of the person as she is independent and appears to be held back by her peers. The other person case tracked attends a college course based at a local day service one session a week. Discussions held with her evidence that she very much enjoys the course. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 12 Weekly activities are recorded on activity sheets in addition to each individual having a ‘Life and Leisure Experiences Plan’ in place which is developed with the support of allocated key workers. Throughout the inspection all of the service users were supported to access the community at varying times. Records seen and discussions held with a service user and the staff on duty evidence that since the last inspection people are being provided with greater opportunities for community presence and participation however no structured in-house activities were seen to take place during the inspection. Daily routines, religious observance and the promotion of community links and social inclusion were available on the files reviewed in addition to contact sheets detailing all contact made with family and significant others. Records evidence that links with families are well established. Risk assessments have also been developed to support individuals wishing to spend time alone. All bedroom doors are locked when unoccupied and service users are provided with keys to their rooms. Two people currently choose to use this facility. Responsibilities for housekeeping tasks were clearly stated on the two files reviewed. The home has pets and service users play an active role in ensuring they are well looked after. It was reported that one service user who has an interest in dogs was supported on a day out to ‘Crufts’ and very much enjoyed attending the event. None of the current service users smoke. Service users play an active role in menu planning and their signatures were seen documented on the menus, which appeared well balanced. A staff member spoken with shared examples of how the home caters for the cultural needs of one individual living at the home. It was reported that service users are supported with food shopping and that this is done on a rota basis. Lunch was taken with service users and people were provided with choice. Where required assistance was provided by staff and this was offered in a sensitive manner. On the day of the inspection it was a service users birthday and there were plans to celebrate this at a local Indian restaurant during the evening. It was evident that people were very much looking forward to the event. A service user enjoyed making the inspector, staff and service users a drink during the inspection and risk assessments to support this process were seen on the two files reviewed. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health care needs are closely monitored with evidence of regular review with healthcare professionals. Personal support is provided according to individual assessed needs. The home has a satisfactory system of handling, storing and managing medication. EVIDENCE: The healthcare records of the two people case tracked were comprehensive with evidence of people’s health being closely monitored by the staff and relevant healthcare professionals. Preferences in relation to personal support were clearly documented on the care files reviewed and staff on duty confirmed that they have sufficient information for care delivery. Health Action Plans are in place and all healthcare appointments clearly documented. Key workers are provided to ensure consistency and continuity of support. A staff member provided good examples of how the ethnic and cultural needs of one service user is promoted in relation to diet; pictorial images for her room and her hair care needs. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 14 Prescribed medication is supplied by Boots Chemists by the form of the Monitored Dosage System (MDS). The manager stated that all staff have received training in this system. She reported that six staff are currently undertaking the ‘Aset’ Certificate in Managing and Safe Handling of Medicines distance learning course run by Walford College. None of the current service users self administer their medication or are they currently prescribed controlled drugs however the home has appropriate storage facility available. Medication procedures appeared satisfactory at the time of the inspection. Medication was found appropriately stored and well organised. Records evidence that an Associate Specialist based within the local learning disability team, keeps people’s medication under regular review. The homes policy on medication was not reviewed on this occasion. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure in place and procedures to safeguard service users from potential abuse. EVIDENCE: A complaints procedure is in place. No complaints have been referred to the Commission for Social Care Inspection (CSCI) since the last inspection however a recent complaint has been received by the home and is currently being investigated. No referrals have been made adult protection procedures. Staff spoken with reported that they have received training in adult protection and physical intervention. Concerns were expressed in relation to the current physical intervention training used. It was reported that some techniques are inappropriate and do not fully protect the dignity of service users, particularly if used in a community setting. The finances of the two people case tracked were checked by the inspector and were an accurate reflection of the records held. One tin was initially £2.00 over however this was accounted for by all staff on duty. Finances are checked at staff handover and two signatures are obtained on finance records. Personal allowances received were clearly recorded and service users are supported to collect their monies from their bank on a regular basis. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 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 the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been minimal change to the décor of furnishings under the new provider and although this does not pose a risk to service users it does not create a pleasing or pleasant environment to live in. EVIDENCE: The home is conveniently located in a residential area of St. Georges, Telford, close to local amenities within walking distance of Oakengates town and a short journey from Telford Town Centre. A full environmental tour of the home was undertaken. Communal space includes a lounge, sitting room/diner, kitchen with new dishwasher, art room, snoozelem and a secure garden. Service users are provided with a single bedroom, en-suite facilities are not provided. Bedrooms are personalised and it was reported that the two vacant rooms have recently been redecorated. An offensive odour was detected on the first floor landing for which a requirement to eliminate this was made at the previous inspection. The two bathrooms located on the first floor currently do not present pleasant rooms to bathe. Although a new bath panel has recently been fitted in one bathroom, the bathroom suite is of mixed colour and the wall tiles remain odd. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 17 Both toilets required a thorough clean as identified in a recent Regulation 26 report in addition to sponges found with no indication of whom they belonged to. No toilet roll was available in two toilets. The garden furniture was found rotten in places and staff expressed concern regarding the safety of service users. A planned maintenance and renewal programme is in place. It was reported quotes were obtained in December for the replacement of carpets to the hall, stairs and landing and bedrooms however works remain outstanding. One person referred to the home as looking ‘tatty’. The Fire Officer visited the home on 1st March 2006 and advice was given in relation to the the kitchen door and the need to record this on the homes fire risk assessment. The manager reported that she has updated the necessary records and sent them to the fire officer and is awaiting approval. It was reported that the Environmental Health Officer has not visited the home since the last CSCI inspection. With the exception of the toilets on the first floor and the cobwebs on the backstairs the home was found clean and tidy. Service users have a responsibility to assist with household tasks and have allocated days for undertaking their laundry. COSHH Data sheets and risk assessments are available for the products used within the home. The manager reported that she has undertaken training in infection control however some staff still require training in this. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are safeguarded by the homes robust recruitment procedures and are supported by a committed, trained and enthusiastic staff team. EVIDENCE: Due to the behaviours displayed by one individual the inspector was unable to fully observe work practices throughout the whole of the day. When opportunities arose staff were seen to be accessible and interacted with service users appropriately. Discussions held with three permanent members of staff evidenced that staff are knowledgeable and have a good understanding of the individuals they support. Staff spoke positively about their roles and responsibilities and appeared motivated and committed to their work. The team consists of eight support staff plus the manager. The manager reported that one staff member holds an NVQ award, one is awaiting verification and three are currently undertaking the award. All three staff spoken with reported that staff morale is good and the team works well. Staff expressed concern in relation to the huge amount of paperwork, which is duplicated in places and time consuming for example health; appointments are recorded on Health Action Plans in addition to a further record. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 19 Since the last inspection three support staff have been recruited. Their personnel files were reviewed and contained the relevant documentation required. CSCI have agreed for the organisation to hold CRB disclosures at the head office. CRB Tracker forms are held in the home and these were seen at the inspection. The personnel file of the person recruited in December 2005 contained evidence of regular formal supervision and a training portfolio. It was reported that service users were not actively involved in the recruitment of the two new staff and reasons for this were shared with the inspector. On arrival to the home two very newly employed support staff were undertaking LDAF induction supported by a tutor. Discussions held with them indicate that they are looking forward to working for the organisation. Staff reported that they continue to be provided with very good training opportunities and individual training records are available. The manager has identified a number of courses, which would benefit her team and these include team building, assertiveness, self harm and foot care. One staff member spoken with felt the team would benefit from training in mental health, which would provide the team with a greater understanding of the needs of the people accommodated. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is effectively managed and promotes the health and safety of service users and staff. The homes aspects of performance are regularly reviewed. EVIDENCE: The registered manager of the home is Ms Paula Johnson, who is contracted to work 40 hours per week with 16 hours designated for management duties and the rest of her hours are for providing direct support. She has completed the NVQ level 4 Care award and is currently undertaking the Registered Managers Award. Since the last inspection she has undertaken numerous training courses appropriate to her role to include quality assurance, stress management, empowerment of service users, NVCI- physical intervention and courses in safe working practices. The manager is line managed by Ms Anne Morrison, Area Manager. Discussion held with the manager identified that Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 21 managing the service in the designated 16 hours a week is becoming increasingly difficult, particularly due to the needs of the service users, large amounts of paperwork and no deputy manager to assist her. Staff on duty reported that the manager is open, approachable and a good listener. The manager has not yet had the opportunity to formally seek the views of service users, relatives, stakeholders etc on how the home is performing. A comprehensive Quality Assurance Audit was undertaken on 21.12.05 and the home scored 74 . A further audit of the home was undertaken on 14.03.06 and a score of 88 was achieved. The report was generally positive with recommendations being made in areas to include communication profiles, Talk Time, service users participation in recruitment and opportunities for skill development of service users. The manager is working towards addressing the recommendations made. A letter of appreciation of the teams hard work and commitment was seen from the Operations Director. Monthly visits required under Regulation 26 are undertaken by the organisation and a report forwarded to the local CSCI office. An annual development plan is in place. The home also monitored by the Borough of Telford and Wrekin’s contract department in relation to a spot contract in place with one service user who is placed by the authority. A report seen dated 25.07.05 recommended that the cultural needs of one service user be better met in relation to décor, activities and meals. Health and Safety procedures appeared satisfactory at the time of the inspection. A health and safety policy is available however this was not reviewed on this occasion. A health and safety audit is conducted monthly and records indicate the last one was undertaken on 20.05.06. Relevant service certificates were available and valid in addition to records of accidents, fire, drills, emergency lighting, water temperatures and other checks undertaken. A training matrix for mandatory training is in place and all staff spoken with confirmed that they have received training in safe working practices which was also evidenced in a training portfolio seen on the personnel file of the person recruited in December 2005. One incident has been reported to RIDDOR and CSCI as a precautionary measure and a risk assessment put in place. However no further measures are since deemed necessary. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 22 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 x 3 x 4 x 5 3 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 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 3 x Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 13(4) 23(2) Requirement Timescale for action 01/09/06 2. 3. YA30 YA30 4. YA39 The homes premises must meet service users individual and collective needs in a comfortable and homely way. 16(2)(k) The offensive odour on the first floor landing must be eliminated. 13(3)(4) The premises must be kept 16(2)(j)(k) clean and hygienic and cleaning of toilets included on the homes cleaning schedule with toilet paper made readily available. 24(1)(a)(b)(2)(3) The views of service users, family, friends and of stakeholders must be sought on how the home is achieving goals for service users. 01/08/06 10/07/06 30/09/06 Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 24 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. 3. 4. 5. 6. Refer to Standard YA6 YA6 YA11 YA14 YA32 YA37 Good Practice Recommendations It is recommended that person centred plans be developed with all service users as soon as possible. It is recommended that an Individual Reactive Management Plan be developed with the support of the local team for the person identified as soon as possible. It is recommended that opportunities for life skills be further developed for one individual in particular. It is recommended that more structured in-house activities be made available. It is recommended that staff receive training in mental health. It is recommended that the managers 16 hours for undertaking managerial work be reviewed. Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Faycroft DS0000065004.V293977.R01.S.doc Version 5.1 Page 26 - 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!