Inspection on 09/01/07 for Fiennes House

This inspection was carried out on 9th January 2007.

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

The inspector 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

Fiennes House 18/12/08

Fiennes House 15/11/05

Fiennes House 16/06/05

Fiennes House 19/01/05

Fiennes House 09/09/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Fiennes House Drakes Park North Wellington Somerset TA21 8TB Lead Inspector Pippa Greed Unannounced Inspection 9th January 2007 09:20 Fiennes House DS0000038170.V323830.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 Fiennes House DS0000038170.V323830.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. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fiennes House Address Drakes Park North Wellington Somerset TA21 8TB 01823 661529 01823 662319 fienneshouse@seeability.org 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) SeeAbility Mr Stephen Rowland Mudway Care Home 7 Category(ies) of Learning disability (0), Physical disability (0), registration, with number Sensory impairment (0) of places Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 7 persons in categories LD, PD and SI. Date of last inspection 15th November 2005 Brief Description of the Service: Fiennes House is registered with the Commission for Social Care Inspection to provide personal care for up to seven people under the age of 65. It is registered in the categories of sensory impairment, physical disability and learning disability. The registered manager is Mr Steve Mudway and the providers are See Ability, a registered charity. The home is purpose-built and situated close to all the amenities of Wellington. All bedrooms are single occupancy, five service users have full en suite facilities and two service users share an assisted bathroom. The home is surrounded by well maintained landscaped gardens, including a ‘sensory’ garden. The gardens are fully accessible for wheelchair users. In addition to the home, there is an activity and resource centre adjacent to the home that service users can access. This is known as the Bill Cooke Centre. The current fee level is £1,867.72 per week. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The previous key inspection was unannounced and took place on 15th November 2005. At that inspection two requirements and three recommendations were made. These have been met. This unannounced Key inspection was conducted over one day (7.5hrs) by CSCI Regulation Inspector Pippa Greed. On the morning of the inspection, three support workers, one administrator and the manager were on duty. During the afternoon, there were three support workers. There were one waking night and one sleep in staff rostered for that evening. The registered manager Mr Steve Mudway was available to assist the inspector during the unannounced visit. On the day of the inspection seven service users were at home initially. Two service users enjoyed a beauty makeover session and one service user had a one-to-one session. Three service users left around mid morning to attend bread-making session at the Bill Cooke Day Centre. Three service users accessed physiotherapy session during the afternoon. Service users were seen to make choices and were offered in-house activities and stimulation. The atmosphere was relaxed and informal. Staff were seen to work professionally and demonstrated good rapport with the service users. The inspector viewed all communal areas and six service users rooms. The inspector met with and engaged with six service users. The inspector sat with the service users and staff and also observed daily routines within the home. The inspector met with two staff members in order to gain insight on training, supervision and how staff understood service users care needs. Selected records were examined. These included four service users care plans and three staff recruitment files. CSCI sent out feedback cards for three service users, three relatives, six staff, one social worker, one health care worker and two General Practitioners. Three service users surveys have been received, which was completed with advocated support. These reflected positive comments. Two comment cards were received from parents. The parents confirmed that they were made welcome, and felt satisfied with the overall care provided at Fiennes House. Five care staff comment cards were received. Staff confirmed that they receive regular supervision, and training updates. They also confirmed that they are clear on service users needs. Two GP comment cards have been received and these confirmed that the service provides good care. The inspector would like to thank the service users, staff, and manager for their time and hospitality shown to the inspector during her visit. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 6 The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: What has improved since the last inspection? The home has obtained a copy of the Department of Health guidance ‘No Secrets’ and the Somerset Safeguarding Vulnerable Adults policy. The homes’ abuse policy has been revised to reflect guidance contained within ‘No Secrets’. All staff have been made aware of the correct procedure to follow should an allegation of abuse be received. The sleep in room has been modified in order to minimise noise from boiler sited in next room. The walls and ceiling has been sound proofed along with partition and extra door added. The day centre toilet door has been adjusted to ensure tighter seal around doorway thus ensuring greater privacy. The administration of medication included variable dosage recording. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 8 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 Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides a statement of purpose, and service user guide that clearly sets out the objectives and philosophy of the service. Prospective service users are given the opportunity to spend time in the home prior to admission. Each service user is provided with a clear statement of terms and conditions that sets out the terms and conditions of residency. EVIDENCE: The service user is provided with a Statement of Purpose and a Service User’s Guide. The Service User’s Guide is written in simple, easy to understand English, which can be read to the service user. The guide explains what the prospective service user can expect from Fiennes House. This enables the service user and their family to make an informed choice. Contracts are kept in the service user’s care plan. The Statement of Purpose outline criteria for admission. Applicants would be encouraged to be involved as much as possible in their pre-admission assessment programme. The applicant would have opportunities to visit the Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 10 home as part of the referral, assessment and transition process. A placement would then commence with an initial assessment period of up to three months. The length of initial assessment period is agreed on an individual basis. A review meeting would be held at the end of the initial assessment period to determine whether an appropriate service can be offered. This decision would fully involve the service user, their relatives/ carers and an advocate if appropriate. Two service user’s survey confirmed that they had a say in choosing the home with advocated support. The service users also confirmed that their family were provided with enough information about the home. The home has a stable service user group therefore has not admitted a new service user in five years. SeeAbility have clear guidance in place should the registered manager and area manager need to complete a pre-admission assessment in future. There is no vacancy at present. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a detailed and well-written care plan for each service user. Service users are encouraged to exercise choice and participate in all aspects of life within the home. Service users are supported in taking risks. Records relating to service users are stored securely and appropriately maintained. EVIDENCE: The inspector sampled four service users care plans. Care plans are well maintained for each service user. Care plans included a photograph of the service user, and provided information regarding service users needs, daily routines and preferences. The care plans also included records of review meetings, visits to health care professionals, and contact with families. Those care plans seen had been regularly reviewed and updated. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 12 However, it is recommended that current funding authority details are made more prominent in the care plan for ease of access. It is also recommended that a summary sheet be inserted in each care plan to signpost where specific service users risk assessments are kept. Individual risk assessments had been completed for each service user. This is kept in a separate risk assessment file. Risk assessments seen have been reviewed and updated. Service users are encouraged to exercise choice. This is done through individual communication system. The inspector observed staff interaction with service users during the inspection process. Staff were seen and heard to offer service user choices of activities and snacks. This was exercised through individual communication method using staff’s understanding of service user’s vocalisation, facial expression or body language, which indicated their chosen preference. Hand over hand signs are used to communicate through touch with some service users, for example drink, meal, and toilet. A Speech Language therapist has supported one service user with their specific communication needs. The service user uses a talk machine, which enables the service user to choose phrases through a facial touch pad. This is positive outcome. The manager informed the inspector that service user’s meetings take place on a monthly basis. This provides service users and their key-worker opportunities to reflect and review their needs. Other examples of quality assurance monitoring are offered through monthly visits (regulation 26), service users and family surveys. The home keeps individual day to day records that detail the activities and choices that have been made by service users. Financial records were seen for two service users. Two staff signatures supported all entries. The entries were correct for expenditures and tallied with the balance. All records relating to service users are stored securely. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home supports the service user with personal development. The home offers service users opportunities to engage with peers, access appropriate leisure activities, and exercise choice. Service users are supported with friendship and family contact. Service users rights and responsibilities are respected. Service users are offered a choice of menu, and the options are developed around their preferences and dietary needs. EVIDENCE: On the day of the inspection, service users were accessing a range of activities, some of which were beauty makeover, bread making, in-house activities and physiotherapy. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 14 An activity timetable listed food experience, one-to-one physical exercise, candle making, aromatherapy, reflexology, art, pottery, basic cookery, games & puzzles, horse riding and afternoon tea, piano and sensory room, creative stories, swimming and lunch out. Service users also access the local community and go out on environmental visits. They are able to pursue their personal hobbies and interest within the home. In-House activities include relaxing with sensory fibre optics, keyboarding, cookery, listening to music and massage. The home has access to the adjacent day centre, which provides a large sensory room equipped with tactile surfaces, beanbags, and variety of lighting. The home also has a quiet room, which is used as additional communal space for relaxing on soft mats and large beanbags. Tactile pictures and murals were displayed throughout the home, which lends to a relaxing ambience. All service users have enjoyed a holiday to Calvert Trust in September 2006. A service user was observed participating in chosen activity. Through the interaction and communication, it was evident that staff are well motivated and clearly understood the service users needs. The inspector noted that the lunchtime routine was relaxed and unhurried. The meal prepared was appetising and freshly made. The home has a pleasant and spacious dining room that was comfortable to eat in. Fresh fruits were available. The staff team offer service user choices in all aspects of food and drink and are very aware of the likes and dislikes of the service users. Food monitoring system are in place where needed. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 15 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): 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 appropriate assistance to meet their personal care needs. The home supports service users in accessing healthcare services. The home has a medication policy, which provide staff with clear guidance. Medication records are managed safely. EVIDENCE: The home has appropriate aids and equipment to support service users mobility. The health and safety checks for these equipments are maintained regularly. It was evident from the care plans through regular monitoring that any changes in the service users wellbeing or behaviour would be identified. The manager and staff team would then take pro-active steps to address and meet changing needs. This was evident in service users care plan that were sampled. These included a multi disciplinary approach with medical Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 16 professionals or support provided from speech and language therapist. Service user’s wellbeing appeared to improve after a period of ill health. Another service user appeared to benefit from communication support aid. The care plans that were sampled contained documentation of the visits made to health care professionals. These included visits to the GP, dentist, chiropodist, optician, physiotherapist, speech & language therapist and consultant psychiatrist. Records are kept of all visits and consultations. A log is also maintained for medication taken on home visits. The home’s procedures for the management and administration of medication were examined at this inspection. Medications were seen to be handled and stored appropriately. The Medication Administration Record clearly demonstrated that two staff signatures confirm all hand transcribed entries. The home has a detailed medication policy file. Variable dosage is recorded appropriately on the Medication Administration Record sheet. Photographs of service users are stored on their medication care profile. Emergency epilepsy protocols were prominent within the medication storage area and provided clear procedures to follow. Returned medications were logged appropriately including reasons for disposal. Staff wrote expiry dates on liquid medication, which is good practice. At present the care plan does not contain details relating standard 21 in the care plans. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place for the protection of vulnerable adults from abuse. The home has a complaints procedure and policy relating to the Protection of Vulnerable Adults. EVIDENCE: The home has appropriate policies relating to the Protection of Vulnerable Adults (POVA), Whistle Blowing, Complaints and Grievance policy. The home’s Whistle Blowing policy has been revised to make clear that all allegations of abuse are recorded and investigated in line with the Somerset Safeguarding Vulnerable Adults policy and in conjunction with other agencies as appropriate including the Police, Social Services and the Commission for Social Care Inspection. The home’s policy and procedure in relation to abuse has been revised to reflect good practice and guidance contained within the Department of Healths ‘No Secrets’ document. Staff have received further training and have been made aware of the correct procedure to follow should an allegation of abuse be received. The home has a copy of the Somerset Safeguarding Vulnerable Adults policy and the Department of Healths guidance ‘No Secrets’. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 18 The home has a number of systems to safeguard vulnerable people, which include a recruitment policy. This means that new staff does not start work at the home until a satisfactory POVA check and an enhanced Criminal Records Bureau (CRB) clearance has been obtained. The inspector met with staff members and asked about their understanding of Safeguarding Adult procedures. Staff knew of the policy, who to report to and confirmed that they have received POVA training. The complaint log was sampled and the last recorded complaint was made in October 2006. Two entries were not directed at the home but external grievance issues. The manager has communicated effectively and recorded details as good practice. Three staff recruitment files were seen to be robust and contained records required in Schedule 2, Care Homes Regulations. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has been decorated and furnished to a high standard. Appropriate adaptations have been provided. The home has sufficient communal areas and bathrooms to meet service users’ needs. The home was found to have a high standard of cleanliness. EVIDENCE: Fiennes House is a large modern purpose built house situated in a residential area within walking distance from the centre of the small town of Wellington. The inspector conducted a tour of the premise and found the home to be warm and welcoming with a good standard of cleanliness and hygiene. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 20 The home is arranged on ground level only. The accommodation comprise of seven single bedrooms, five of which have en-suite shower/ toilet facilities and two with en-suite toilet facilities. Four bedrooms offer overhead tracking and hoists and all bedrooms are fitted with an alarm call system. Hoists have been appropriately maintained. Shared facilities are quiet room, one bathroom with a specialist bath, communal lounge, kitchen and dining areas. The building has been designed to promote easy access for wheelchair users and people with vision impairment. The home makes use of contrasting colour scheme, décor, tactile information and specialist lighting. The home is surrounded by well maintained landscaped gardens, including a ‘sensory’ garden and paved barbecue area. The gardens are fully accessible for wheelchair users. In addition to the home, there is an activity and resource centre adjacent to the home that service users can access. Each service users bedroom was specifically decorated to their taste and interest. The bedrooms were filled with a range of décor such as collectibles, personal photographs, keyboard, sensory lighting display, music systems, handmade tactile mural, physiotherapy ball, television, DVD player, and personal memorabilia. The en-suite facilities were also personalised in a bright and cheerful manner. Next to the office is a good-sized laundry room, which houses two large washing machines and a new tumble drier. It was found to be clean and well organised. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are experienced and provide a good standard of care. Staffing levels are appropriate to meet service users’ needs. Staff receive comprehensive induction and training updates. Staff receive appropriate support and supervision. EVIDENCE: Duty rotas are well maintained. On the day of the inspection, there were three staff on duty during the morning, one administrator, one senior and one manager during the day, three staff during the afternoon and one waking and one sleep in staff at night. Since the last key inspection, nine staff has joined the team at Fiennes House. The Manager has completed an analysis of staff training needs, to ensure that all staff are provided with appropriate training to undertake their role. Newly employed staff complete a thorough Induction programme and undertake Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 22 National Vocational Qualification (NVQ). Staff are provided with regular opportunities to receive training, and have attended courses on Health and Safety, Food Hygiene, First Aid, Fire Policy, Epilepsy, Manual Handling, Visual Impairment, Medication Administration, and Minibus. Out of the fourteen residential care staff employed, ten have obtained the NVQ level 2 qualification in care. Three staff recruitment files were examined. These were maintained appropriately. Each was found to contain the documentation required within Schedule 2 of the Care Home Regulations 2001. The inspector viewed the records in relation to staff supervisions. The manager has an overview of all staff supervisions that have been conducted. Senior staff also provides supervision in order to maintain good frequency. The inspector noted that staff has been supervised recently. The inspector spoke with two staff members. Staff confirmed that the manager and senior staff were approachable and that they would be able to raise any concerns. Staff also confirmed that there was a wide variety of training available. This would ensure that they develop the skills and experience necessary to provide a good quality of care for service users. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is very well run and benefits from a competent manager. There is a relaxed and inclusive atmosphere within the home. Health and Safety checks are well maintained and the service users welfare is protected. EVIDENCE: Steve Mudway is the Registered Manager for the home. He has many years experience of providing care to service users with learning disability and autism. Steve has worked with SeeAbility since July 2002 and at Fiennes House since 2005. He has attained NVQ level 3 in care, NVQ Assessor A1 award, and the Registered Manager’s Award. Steve is supported by two senior support workers and one administrator. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 24 SeeAbility has systems in place in relation to financial planning, budget monitoring, human resources, training and quality assurance monitoring. The home has appropriate policies and procedures in place to safeguard vulnerable service users. All records relating to service users are stored securely in accordance with the Data Protection Act 1998. The home has a current Employers Liability insurance. The home operates a comprehensive system of health and safety audits. Fire safety records were examined. Fire equipment had been serviced and tested as required. The electrical hardwiring certificate and landlord gas safety certificates have been appropriately maintained. Hoist checks have been conducted at regular intervals. Accidents have been recorded and an analysis completed on a monthly basis. The monthly analysis are complied by the manager. These were seen to be detailed and thorough. Records are kept of daily fridge and freezer temperatures, and food probes. These were maintained regularly. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 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 3 25 4 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 3 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 3 3 3 3 4 3 Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA9 Good Practice Recommendations It is recommended that current funding authority details are made more prominent in the care plan for ease of access. It is recommended that a summary sheet be inserted in each care plan to signpost where specific service users risk assessments are kept. Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Fiennes House DS0000038170.V323830.R01.S.doc Version 5.2 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. 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