CARE HOME ADULTS 18-65
Fishermead Boulevard (104) Fishermead Milton Keynes Bucks MK6 2AP Lead Inspector
Nancy Gates Unannounced Inspection 6 & 18 December 2006 3:30
th th Fishermead Boulevard (104) DS0000015057.V316909.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 Fishermead Boulevard (104) DS0000015057.V316909.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. Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Fishermead Boulevard (104) Address Fishermead Milton Keynes Bucks MK6 2AP 01908 670234 01908 670234 manager.fishermead@fremantletrust.org Manager.winglodge@fremantletrust.org The Fremantle Trust 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) Mrs Susan McMillan Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: 104 Fishermead Boulevard is located close to the city centre in Milton Keynes. There are good shopping, leisure and transport facilities close by. The home is a large, detached property with accommodation on two floors. There is one downstairs bedroom with the remaining five on the first floor. 104 Fishermead Boulevard is home to 6 people who require support and accommodation on a 24-hour basis. The current fees for this service are £529.69 per week. Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. From the 1st April 2006 the Commission for Social Care Inspection (CSCI) has developed the way it undertakes the inspection of care services. The inspection of the service was an unannounced ‘key inspection’. The inspector conducted to visits to the home in December 2006 arriving at the service at 15.30 p.m. on the first visit and at 8.30 am on the second visit. The total number of hours spent at the home was 6 hours. The time spent at the home allowed for a thorough look at how well the service is doing. The inspection took into account detailed information provided by the service manager inclusive of information that CSCI has received about the service since the last inspection. The inspector asked for the views of the people who use the service. The inspector also asked the views of others who support the needs of the people who use the service via a questionnaire that the CSCI sent out. 2 members of staff were on duty on both occasions. Staff and residents were very welcoming. The inspector looked around the home including the bedrooms of the residents at their invitation. A number of records were viewed including a resident’s care/support plans, staff recruitment records, staffing rotas and maintenance records. The inspector looked at how well the service was meeting the standards set by the government. The report includes judgements about the standard of the service offered. What the service does well:
No admissions have been made to the home, although the assessments completed for current residents provide good quality of information for admission. Individual Person Centred Plans and personal information is written and maintained at an excellent standard. The plans clearly centre on the preferences and wishes of service users and are inclusive of the contribution of a number of people involved in the individual’s life. Reviews are conducted on a regular basis allowing for the support provided to be consistent, safe and relating to changing needs and wishes. Guidance is also provided from appropriate professionals allowing for support to relate to needs and wishes. Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 6 Service users are enabled to take risks, in order that they are as independent as possible. Service users are supported to make lifestyle choices, which recognise individuality and are enabled to take risks within these choices. Acceptable risk taking remains part of the home’s philosophy. Service users have opportunities for personal development, in order to lead fulfilled and independent lives. Service users’ rights and responsibilities are upheld, they clearly have a say in their support. Service users lead active lives with a range of opportunities available to them during the week and at weekends. Hobbies are actively pursued, especially supporting football teams. Good use is made of the local community and service users maintain links with families and friends. Service users are offered a good diet, in order that nutritional needs are met. Residents’ personal and healthcare needs are appropriately supported. Staff continue to provide personal support in ways, which service users prefer, in order that their needs are best met. Staff clearly promote service users’ physical and emotional health, to keep them healthy and well. Access to additional support from health care professionals is consistent and meets residents’ health needs. The storage and administration of medication ensures the protection of residents. Medication practice is well managed at the home, to ensure that service users health and well-being are promoted. From the evidence seen, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. A clear complaints process is available to residents and their representatives. There continues to be an effective complaints procedure in place, to listen to the views of service users. Protection of residents is assured by the availability of adult protection guidance, appropriate training and staff awareness. Appropriate arrangements are in place to protect service users from risk of abuse, to promote their safety and well-being. A clean, homely, well-maintained and comfortable environment is provided. Service users bedrooms reflect individuality. The design and layout of the home, inclusive of adaptations for one individual meet the needs of service users. The home is clean and hygienic, continuing to guard against the risks of infection and ill health. Staff are attentive and respectful promoting communication and independence in relation to need. Competent and qualified staff work at the home.
Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 7 The qualifications attained by staff underpin the support needs of service users. Training provided to staff ensures that they are competent and qualified to meet service users needs. Staff are supervised appropriately. Staff records indicate that the recruitment process ensures the protection of residents. The home continues to be effectively managed, to ensure that care needs are consistently met. There is regular monitoring by the provider, to ensure that the home is efficiently run and providing good standards of care. Records are well-maintained, safeguarding service users’ best interests. Effective management of health and safety ensures the continued welfare of service users, staff and visitors safe. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fishermead Boulevard (104) DS0000015057.V316909.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 Fishermead Boulevard (104) DS0000015057.V316909.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No admissions have been made to the home, although the assessments completed for current residents provide good quality of information for admission. EVIDENCE: No admissions have been made to the home since the previous inspection. Information for prospective service users accurately describes what the home has to offer. The assessments completed for current residents provide good quality information for admission. The current fees for this service are £529.69 per week. Fishermead Boulevard (104) DS0000015057.V316909.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 excellent This judgement has been made using available evidence including a visit to this service. Individual Person Centred Plans and personal information is written and maintained at an excellent standard. The plans clearly centre on the preferences and wishes of service users and are inclusive of the contribution of a number of people involved in the individual’s life. Reviews are conducted on a regular basis allowing for the support provided to be consistent, safe and relating to changing needs and wishes. Guidance is also provided from appropriate professionals allowing for support to relate to needs and wishes. Service users are enabled to take risks, in order that they are as independent as possible. EVIDENCE:
Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 11 The Person Centred Plans (PCPs) of three people who live at the home were viewed by the inspector with their permission. The documents provide clear information as to how each person likes to be supported and it was clear that the individuals, their families and friends contributed throughout the whole process of writing the plan. The plans also relate to a person’s communication support needs, clearly identifying and guiding staff in the interpretation of sound and gesture for one individual. Clear description and recognition of who people are as individuals contributes to establishing trusting and supportive relationships. A section of each person’s plan provides details of ‘likes and dislikes’, “ Tea with two sugars…choosing my own breakfast…staff being funny and making me laugh…dancing…I don’t like being bossed around and being asked to do more than two things at once….” The plans give opportunity for personal likes and wishes to be prioritised, for routines to be established when people require them and for personal preferences to be acknowledged. The use of photographs also provides a clear understanding of support needs and how a person likes to be supported. The inspector observed that all staff members were following the direction of the individuals’ plans. The PCPs included assessment of risk and actions to minimise risk. Individuals are supported to consider activities and lifestyle choices within a risk guidance framework that ensures their safety, whilst undertaking activities of their choice. Fishermead Boulevard (104) DS0000015057.V316909.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 excellent This judgement has been made using available evidence including a visit to this service. Service users are supported to make lifestyle choices, which recognise individuality and are enabled to take risks within these choices. Long-standing friendships and relationships are supported demonstrating respect for individuality. Service users have opportunities for personal development, in order to lead fulfilled and independent lives. Service users’ rights and responsibilities are upheld, they clearly have a say in their support. Service users are part of the local community, promoting independence and self-worth. Service users are offered a good diet, in order that nutritional needs are met. EVIDENCE:
Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 13 Person Centred Plans (PCP’s) describe preferences, likes, dislikes and favourite lifestyle activities. The complex needs of one service users could be seen to hinder choice, but the staff and manager have made a clear commitment to ensuring all household members are able to fulfil their wishes as far as practically possible, and at times being supported/given the opportunity to take risks. A large activity chart/weekly diary is posted in the study; each persons chosen activities are listed for each day. Service users continue to be are involved in various activities during the week and at weekends. Day services such as Thrift Farm, Tower Drive, Snaps and Beanhill are available. Person Centred Plans list a range of interests and activities and clearly highlight individuality. People described their love of football and their ‘teams’, recalling visits to watch local and Premiership games. One person was seen to be contacting friends using a mobile phone highlighting respect for anonymity and independence. Most of the service users have verbal communication skills and can make their needs readily known. Staff responded to non-verbal cues for one person and used picture cards to indicate preferences and check responses had been understood correctly. The ‘likes’ for a number of people were recorded as follows, “I like listening to music…playing my X Box…watching football, especially Manchester United…going to the pub…restaurants…bowling…going to the cinema..watching Sky TV, especially Buffy the Vampire Slayer…seeing my girlfriend.” Evening clubs and groups are available, service users described their enjoyment of ‘Groovy Gecco’ (an evening at a local nightclub for people with learning disabilities), where dancing and socialising with friends has clearly become a valuable part of peoples lifestyle. Long standing friendships and relationships are supported appropriately. One person was going to his girlfriend house for diner to celebrate her birthday; another person has bought a new bed so his girlfriend is able to stay over. The manager and staff are aware of potential difficulties that may arise from guests staying and have ensured that the protection of all household members can be assured. Relationships with families are also important and service users family members are clearly involved in people lives. Contact with families and friends is good with people enabled to stay with their families at weekends. Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 14 Service users continue to make good use of the facilities close by; shops in the city centre are within a ten minute walk and some people go into the centre unaided. The daily routine of the home continues to be flexible and unrushed, although planned social activities meant that people ere prompted to get ready to ensure they were ready to go out. Preferred form of address was being used with service users and there was good interaction between all house members. All household members are involved in the planning of what they want to eat, either as individuals or as a group. A varied selection of food options is available. Records of food consumed by service users were varied, with a range of different meals provided for them. The majority of service users are able to make their own drinks and snacks when they want to, often offering to make drinks for others. The specialist dietary needs of service users are supported appropriately in consultation with health care professionals. Fishermead Boulevard (104) DS0000015057.V316909.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): 18, 19 & 20 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents’ personal and healthcare needs are appropriately supported. Staff continue to provide personal support in ways, which service users prefer, in order that their needs are best met. Staff clearly promote service users’ physical and emotional health, to keep them healthy and well. Access to additional support from health care professionals is consistent and meets residents’ health needs. The storage and administration of medication ensures the protection of residents. Medication practice is well managed at the home, to ensure that service users health and well-being are promoted. EVIDENCE:
Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 16 Support plans/Health passports detail clear guidance of how residents wish their personal and healthcare needs to be supported. The manager and staff have made a clear commitment to ensuring that the plans are reviewed on a regular basis. One person continues to require full assistance with personal care and this was carried out in private, with respectful conversation throughout with the individual on what needed to be done. The manager has ensured that appropriate equipment is available to assist with the individuals’ daily living tasks, and staff were seen to be using the equipment appropriately. The care needs of the individual are written within very descriptive support plans providing staff with clear guidance and procedures, which ensure the individuals health and welfare is supported as far as possible. The manager has developed close links with local health care professionals, using every opportunity to ensure that residents are receiving appropriate health care support when required. Residents are appropriately supported to access health services and are registered with a local doctor. Medication reviews are conducted with the doctors on a regular basis. Records showed that staff are continuing to promote attendance at routine health care appointments as well as preventative screening offered. Staff clearly promote emotional health. One individuals record stated, “So if I’m looking a little sad or withdrawn, I may need someone to spend a little extra time with me.” Medication storage and administration records (MARs) were viewed. A lockable cabinet, which was securely attached to the wall, ensures the safe storage of medication. Medication administration records were well maintained with signatures alongside prescribed dose times. No omissions were noted; records were accurate and up to date. One individual is being supported to manage the administration of their medication. The individual described how support has been provided to write information in a PCP about “how to help me take my tablets”. The person was able to clearly describe how to take the medication, what had to be taken, the colour of the blister packs that relate to specific times of day and that a signature was required once the “tablet” had been taken. The inspector commends the manager and staff for recognising and supporting the individuals’ autonomy, whilst balancing risk with a person’s request for independence. Fishermead Boulevard (104) DS0000015057.V316909.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): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A clear complaints process is available to residents and their representatives. There continues to be an effective complaints procedure in place, to listen to the views of service users. Protection of residents is assured by the availability of adult protection guidance, appropriate training and staff awareness. Appropriate arrangements are in place to protect service users from risk of abuse, to promote their safety and well-being. EVIDENCE: No formal complaints have been received at the home or at the CSCI since the last inspection. A complaints policy, procedure and information for residents are available at the home. Residents commented that they are able to vocalise the concerns if they’re not happy. The procedure contains the contact details of the Commission for Social Care Inspection for reference. The home continues to have whistle blowing and Protection of Vulnerable Adults procedures in place. Staff training records showed training regarding the Protection of Vulnerable Adults is being undertaken. Staff members spoken with were able to provide a good account of how to respond to
Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 18 allegations. Staff members also confirmed that they have been made aware of the whistle blowing policy. Fishermead Boulevard (104) DS0000015057.V316909.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): 24 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A clean, homely, well-maintained and comfortable environment is provided. Service users bedrooms reflect individuality. The design and layout of the home, inclusive of adaptations for one individual meet the needs of service users. The home is clean and hygienic, continuing to guard against the risks of infection and ill health. EVIDENCE: The home is large detached property, close to local facilities and shops. All parts of the home other than one locked bedrooms were seen with the permission and assistance of service users. Communal areas were bright and warm and decorated to a good standard. All of the shared spaces within the
Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 20 home are accessible to the majority of service users for shared and private use. Adaptations, specifically relating to one service users needs, have been installed and are regularly maintained. The lounge and dining room are clearly very socialable areas. The dining room, which is next to the open plan kitchen, contains a hi-fi system and a computer for use by all house members. This seemed to be the hub of the house. Music was being played with the addition of conversation whilst people were cooking/getting hot drinks and this presented a very ‘family-like’ atmosphere. People appeared to congregate after arriving home to talk and share with staff what had happened during the day or to talk about plans for the evening. Service users’ bedrooms reflect individual tastes, containing personal effects that ensure that individuality is recognised. Posters of football teams, celebrities, pop stars in addition to linens, which also showed football preferences added to the ‘lived in’ feel. Service users commented that they think the house “is a nice place…I like my room, these are all my things…I help to clean my room on home days.” An individual commented that a new bed was being bought which has a “guest bed for when my girlfriend wants to stay.” It is clear that important relationships are acknowledged and supported, but that this is done considering all household members with risk minimised. The home was bright, clean and tidy and warm. The laundry was clean and tidy. No offensive odours were evident. Fishermead Boulevard (104) DS0000015057.V316909.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): 32, 34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are attentive and respectful promoting communication and independence in relation to need. Competent and qualified staff work at the home. The qualifications attained by staff underpin the support needs of service users. Training provided to staff ensures that they are competent and qualified to meet service users needs. Staff are supervised appropriately. Staff records indicate that the recruitment process ensures the protection of residents. EVIDENCE:
Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 22 Two people were on duty at the start of the inspection, had worked at the home for some time and knew service users well. No agency staff were being used at the home at the time of the visits. The inspector had the opportunity to speak with the two members of staff to explore their knowledge of supporting service users. Both staff members demonstrated a sound knowledge of the needs of service users, had a clear understanding of care needs and the importance of promoting choice and individuality. A diverse training programme offered by the Freemantle Trust underpins staff members’ knowledge base. Both were up-to-date with mandatory training and overall, training records showed that several staff had updated their knowledge during the year. All staff to support the complex needs of one individual have completed specialist training, the training being provided by health care professionals. Recent changes in the number of hours required to support a service user at home has required staff to change their working pattern, develop new skills and be presented with additional challenges, but this does not appear to have affected their approach to supporting people. The staff demonstrated throughout the inspection a commitment to not only meeting the needs of one individual but to ensure that all other house members wishes/needs are respected and acted upon. Interaction with residents was positive and respectful. Staff recruitment records are held at the home and contain the relevant information for the protection of all house members. Fishermead Boulevard (104) DS0000015057.V316909.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): 37, 39 & 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home continues to be effectively managed, to ensure that care needs are consistently met. There is regular monitoring by the provider, to ensure that the home is efficiently run and providing good standards of care. Records are well-maintained, safeguarding service users’ best interests. Effective management of health and safety ensures the continued welfare of service users, staff and visitors safe. Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager described a range of skills and experience for the support of the service user group and has achieved the Registered Manager’s Award. The manager continues to be registered with the Commission, training records indicate periodic training is undertaken to refresh skills. Regular monthly visits have been undertaken by the provider to evaluate quality of care and reports of these visits are routinely held at the home. Records examined within the inspection were accurate and up to date. A range of health and safety checks continue to be carried out at the home. Checks are made of fridge and freezer temperatures and cooked food core temperatures. The fire log showed that routine tests are carried out and that maintenance and servicing takes place. Additionally a fire based risk assessment was in place and there were assessments where service users do not respond to the fire alarm. Generic and individual risk assessments were in place. Protective gloves and antibacterial hand wash were available around the building. Records were being maintained of any accidents and incidents around the home and appropriate action had been taken in response to these. Fishermead Boulevard (104) DS0000015057.V316909.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 X 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 3 X X 3 X Fishermead Boulevard (104) DS0000015057.V316909.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. Refer to Standard Good Practice Recommendations Fishermead Boulevard (104) DS0000015057.V316909.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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
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