Inspection on 10/02/04 for Flaxpits House

Care Homes For Adults (18 ­ 65)Flaxpits House74 Flaxpits Lane Winterbourne South Glos BS36 1LBUnannounced Inspection10th February 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Flaxpits House Address 74 Flaxpits Lane, Winterbourne, South Glos, BS36 1LB Email Address admin@aspectsandmilestones.org.uk Name of registered provider(s)/Company (if applicable) Aspects and Milestones Trust Name of registered manager (if applicable) Miss Dionne Marie Brown Type of registration Care Home No. of places registered (if applicable) 8 Tel No: 01454 776191 Fax No: 0117 9709301Category(ies) of registration, with (number of places) Learning disability (8), Learning disability over 65 years of age (8), Physical disability (8), Physical disability over 65 years of age (8) Registration number D050000934 Date First registered Date of latest registration certificate 1st August 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspection 6th November 2003 YES YES 23.04.03 If Yes Refer to Part CFlaxpits HousePage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 310th February 2004 09:30 am Odette Coveney Paula CordellID Code145544 083580Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Dionne Browne. the time of inspectionFlaxpits HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where applicable) Providers Response Providers Comments Action Plan Providers AgreementFlaxpits HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the NCSC in respect of Flaxpits House. The inspection findings relate to the National Minimum Standards (NMS) for Care Home published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000 and the Children Act 1989 as amended. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Flaxpits HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Flaxpits House is a detached property there is a large garden to the side and rear of the property, which is fenced for privacy. There are lawns, flowerbeds a summerhouse and a recently purchased greenhouse. To the front of the property is a large area of hard standing which provides ample parking as well as mature trees and shrubs. The property was originally a period house which has been renovated and extended to provide accommodation on two floors, there are plans to extend the property further to incorporate an independent living unit and another two bedrooms, although these plans have yet to be finalised. All of the bedrooms are single occupancy and there is a choice of communal rooms, which all have access to the gardens. The home is close to the centre of Winterbourne, which is served by a bus service to Bristol city centre and is within easy access to the motorway. Flaxpits House is part of the Aspects & Milestones Trust; the home provides residential care for eight adults with learning and physical disabilities. The registered manger is Dionne Browne, who has been in post since June 2003.Flaxpits HousePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns). Brief IntroductionThis was an unannounced inspection following the announced inspection of 23rd April 2003. The purpose of this inspection was to follow up requirements and recommendations and to also review the quality of care and service being provided. The new Manager has been in post since June 2003 and has been proactive in a number of areas including review of service user support, staff supervision and identifying specific staff responsibility. The inspection took one day to complete, during which the Manager and staff were informative and engaging. The inspector had the opportunity to meet with the Manager, four of the service users and four staff members. Choice of Home (Standards 1-5) 5 of 5 standards assessed were met The homes statement of purpose requires updating The following areas required attention: 1) The age range and specific categories of service user in the home need to be included. 2) The qualifications and experience of staff members to be included. Service users are supported to visit Flaxpits House as part of their admission process, records held confirmed this. Contracts between the placing local authority and Aspects and Milestones were viewed by the inspector, however there were no Contracts/Statement of Terms and Conditions to be found on the premises, the manager was unsure as to whether these were held at the main office of Aspects and Milestone, to be a focus at next inspection. Individual Needs and Choices (Standards 6-10) 5 of 5 standards assessed were met The Manager discussed with the inspector plans to update the current format for the Service user plan. Each service user is allocated a Key Worker who monitors the needs of their resident; staff stated that they take seriously their roles as key-workers. Supervision records detail key worker role and responsibility. The Manager stated that service users were asked on a regular basis if they wished to participate with the day-to-day running of the home. Flaxpits House Page 6 Risk Assessments are in place for each service user, however none of the assessments are dated or signed, therefore it is unclear when the assessments were last reviewed. Lifestyle (Standards 11-17) 7 of 7 standards assessed were met Service users were observed relaxing within the home, staff interacted well, and relationships seemed well established. Service users are able to access local shops and walk around the village. The home has its own mini-bus. Upon the inspectors arrival at Flaxpits House a service user was being taken to Portishead for a cream tea, during the inspection two staff and four service users went out for a trip in the mini-bus. Personal and Healthcare Support (Standards 18-21) 3 of 4 standards assessed were met There are no service users at Flaxpits House who require nursing care. The manger gave many examples during the inspection of how service users are supported, these included flexibility and service user choice in when to retire, when to get up etc.. Information on care files cross referenced with information supplied by the manager in relation to support services which are in place for the service users, examples of these are that there is involvement from the community learning disability team, there is a psychologist working with a service user, therapies have been explored for supporting individuals an example of this was hydrotherapy to aid relaxation. Concerns, Complaints and Protection (Standards 22-23) 2 of 2 standards assessed were met There have been no recorded complaints since the last inspection; it is recommended that the complaints book record actions/outcomes of how complaints are dealt with, however there are robust procedures for dealing with complaints in place which are service user friendly. Environment (Standards 24-30) 6 of 6 standards assessed were met Flaxpits House is a purpose built home; the house has a homely nature. Accommodation is based on two floors, leading from the entrance are the two lounges and dining area, there is access to a large well maintained garden from one of the lounges. There is a plan to extend the property to incorporate two extra bedrooms and create an independent unit for one of the service users, The Manager stated, he will be funding this extension, some discussion took place surrounding issues this may create, the manger explained that the process was very much in the initial stages and she didnt have all of the details, she was going to speak to her line manager to obtain clarification. The NCSC are to be kept informed of the process, as a variation in conditions of registration will be required. Staffing (Standards 31-36) 6 of 6 standards assessed were met The home has a registered manager in post, and a deputy manager; there is a wellestablished staff team. The Staff team have a varied range of knowledge and skills; this includes working in a long stay hospital and transition to care in the community. Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs. Staff training records viewed by the inspector found that not all staff have undertaken five paid days training per year, standard 35.5, it was also noted that three staff members have not undertaken any training since 2002. Supervision records in place were of a high standard, it was evident that supervision is undertaken on a regular basis and that staff are well supported by the manager Flaxpits House Page 7 Conduct and Management of the Home (Standards 37-43) 7 of 7 standards assessed were met The Registered Manager has been deemed a `Fit Person and has been interviewed by the NCSC. Throughout the inspection it was evident that the manager has a commitment to a person centred approach to care and support for the service users. A fire drill had not been undertaken since 16.09.02, it was therefore made an immediate requirement that this be undertaken within the next 24 hours. Emergency lighting should be tested on a monthly basis, this had not been undertaken since December 2003, and it was made an immediate requirement that the lighting be tested within the next 24 hours.Flaxpits HousePage 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 1 4&5 YA1 An up to date Statement of Purpose, which includes the information listed in Schedule 1 of the regulations. A Service Users Guide, which includes the information, listed in regulation 5. An effective Quality Assurance monitoring system based on the views of the Service Users. Regulation 246 Months 6 Months224YA39Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 YA41 Regualtion 17 (2) The Registered Person shall maintain in the care home records specified in Schedule 4. (Schedule 4. (6) A record of all persons employed at the care home, details specified (a)-(f).CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Flaxpits HousePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action Reg 23(4)(c) An Immediate requirement that a fire drill is undertaken, emergency lighting to be tested. Fire door to bedroom to be checked by contractor to ensure it is self closing.1YA 42.2 ii11.02.04.2Reg 4 & 5YA 1It is required that an up to date Statement of Purpose, which includes the information listed 10.03.04 in Schedule 1 of the regulations. A Service Users Guide, which includes the information, listed in regulation 5. It is required that an effective Quality Assurance monitoring system based on the views of the Service Users. Regulation 24 It is required that the menu be expanded to record details of vegetables in diet. 10.08.04Reg 24 3 Schedule 4. 13. 17 (2) Reg 17(2)YA 394YA 1710.03.045YA 34It is required that staff records are to be held 01.04.04. on the premises, including, as per schedule 4. It is required that each service user has a copy of Terms & Conditions between the home and the service user. It is required that he home documents and monitors use of Epilepsy nocturnal monitor 10.05.046Reg 4 & 5 Reg 14 2 (b)YA57YA 910. 03.04Flaxpits HousePage 10 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * 1 2 3 4 5 YA 22 YA 41 YA 35 YA 25 YA 14 It is recommended that the complaints book records actions/outcomes of how issues are dealt with. It is recommended that risk assessment records be signed and dated to demonstrate that they are being monitored It is recommended that the registered manager looks at strategies to ensure that all staff undertake five days training per year. National Care Standards Commission to be informed of finding an independent advocate for a service user. It is recommended that service user holidays are risk assessed and are monitored and recorded accordingly.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Flaxpits House YES YES NO YES YES YES YES NO YES NO YES NO YES YES NO NO NO Page 11 Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs)YES NO YES 5 X X NO NO YES YES 19 1 10/02/04 09:30 6.5The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Flaxpits HousePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives, philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 735 1000 Range of fees charged From To £ Approx £ (per week) YES Any charges for extras Nominal sum for petrol used in minibus If yes, please state what the extras are 2 Key findings/Evidence Standard met? The Manager stated that she had been revising The Statement of Purpose for Flaxpits House, the document contained pictures of the local area and had been written in plain English, however this was found not to be in line with schedule 1 of the Care Homes Regulations 2001. The following areas required attention: 1) The age range and specific categories of service user in the home need to be included. 2) The qualifications and experience of actual staffing to be included. 3) Room sizes of service users bedrooms. The Inspector requires the appropriate amendments to be made and has requested the document is forwarded to the National Care Standards Commission. The Mission statement related to a previous organisation and requires updating.Flaxpits HousePage 13 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user using an appropriate communication method, and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? There have been no new admissions to the home since the last inspection. Service users are admitted to the home following a comprehensive assessment by a care manager, these are available on file for reference. The admission policy/guidelines for staff were viewed by the inspector, also viewed was a compatibility assessment, this had been created to ensure that the existing service users needs were taken into account when a new service user was admitted to the home this is viewed as good practice. Admission Procedure in place, not viewed on this inspection. One service user has their cousin as an advocate. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Service users are supported to visit Flaxpits House as part of their admission process, records held confirmed this. Records also viewed by the inspector demonstrated that the most recently admitted service user was part of a full assessment process, this service user has also been fully assessed in relation to her large number of falls and support services such as the GP, Physiotherapist, and occupational therapist have been involved to try to reduce the likelihood of falls occurring. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis, before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? Within the year there has only been one new admission to the home, the manager spoke of the support given to this service user, this included the person being introduced to the home and to other service users over a period of time, records documented the observations undertaken by staff in relation to the individual and the other service users living in the home. There are no unplanned admissions to Flaxpits House.Flaxpits HousePage 14 Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 1 Key findings/Evidence Standard met? Contracts between the placing local authority and Aspects and Milestones were viewed by the inspector, however there were no Contracts/Statement of Terms and Conditions to be found on the premises, the manager was unsure as to whether these were held at the main office of Aspects and Milestone, to be a focus at next inspection.Flaxpits HousePage 15 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? The Manger discussed with the inspector plans to update the current format for the Service user plan, this will incorporate all of the information currently held, records viewed were service user led and included: My Perfect Day, Pen History, Positive Reputation, information was also held in relation to specific healthcare, personal and social support, all of this will be developed with an Essential Life Style Plan for each service user. Each service user is allocated a Key Worker who monitors the needs of their resident; staff stated that they take seriously their roles as key-workers. Supervision records detail key worker role and responsibility. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions and that right is limited only through the assessment process, involving the service user and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? The Manager stated that service users are supported to make decisions with aspects of their daily living, staff are aware of non-verbal communication as an indicator of decision-making. The Manager spoke of service users rights to make decisions on aspects of their lives and how to balance this with risks. Service users lives do not appear to be restrictive in any way.Flaxpits HousePage 16 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day-to-day running of the home and to contribute to the development and review of policies, procedures and services. 2 Key findings/Evidence Standard met? Service users were observed being asked if they wished to be involved with tasks, those who chose not to, their wishes were respected. The Manager stated that service users were asked on a regular basis if they wished to participate with the day to day running of the home, some service users will assist with laying tables, making their bed, others choose not to. The complaints procedure is in pictorial form. A discussion took place in relation to the Quality Assurance process incorporating the views of the service users and in which format this could take, the Manager stated that she would consider this when she reviews the Quality Assurance process within the home as part of her Registered Managers Award. Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 2 Key findings/Evidence Standard met? Risk Assessments are in place for each service user, these contained action taken to minimise risks, examples included use of transport, risk of abuse from others, the manager had recently completed an assessment on choking, this was found to contain concise information, however none of the assessments were dated or signed, therefore it is unclear when the assessments are last reviewed. One service user had a monitor in their room due to nocturnal epilepsy. No records were in place to support its use. The manager must consider whether the use of this is still appropriate. Records should then demonstrate risk management strategies and review. Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998 and in the best interests of the service user. 3 Key findings/Evidence Standard met? Held within the homes Policies and Procedures folder is a copy of the Data Protection Act 1998. The office where confidential records are held is kept locked when not in use. Records were found to be secure. Staff spoken to were aware of the importance of confidentiality within their role.Flaxpits HousePage 17 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Service users were observed relaxing within the home, staff interacted well, and relationships seemed well established. Throughout the inspection the manager gave examples of how service users are supported to lead an independent lifestyle, this was also viewed in care plans. Service users have attended college to undertake independent activities, such as cooking. The manager told the inspector that staff have recently attended Makaton training which they will incorporate within their role when verbal is not the main form of communication. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities 3 Key findings/Evidence Standard met? Day care workers, funded by South Gloucestershire Council, support individuals, hours are allocated in relation to the individual needs of the service user, one service user is allocated 7.12 hours, and another has 2 staff members to support him with his chosen activities. The manager had identified that one service user who has been through the assessment process for day care services, had identified that additional support is required, Aspects and Milestones are funding this. The manager stated that it is anticipated this support will commence within the next four weeks.Flaxpits HousePage 18 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? Flaxpits House is a well- established care home in a residential area. Neighbours were invited to a Christmas party being held at the home, Christmas cards were exchanged, there have been a number of complaints from neighbours in the past, however there have been no complaints for some time. The manager stated the home has a positive relationship with the neighbours. Service users are able to access local shops and walk around the block. The home has its own mini-bus, which is wheelchair accessible to enable trips out; one service user has their own people carrier. Records were seen for funding arrangements and contracts regarding payment. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to and choose from a range of appropriate leisure activities. 4 Key findings/Evidence Standard met? Upon arrival at Flaxpits House a service user was being taken to Portishead for a cream tea, during the inspection two staff and four service users went out for a trip in the mini-bus. Photographs in the home showed a service user wheelchair ice-skating, which is commendable as this demonstrates there were no discrimination regarding access for this service user. The manager spoke of service users going out to the cinema, theatre, service users attend a drop in club each Thursday and another attends the local conservatory club. This was confirmed in care records, activity plans and discussion with staff. One of the service users has a radio on a time-release button in their room. Staff spoke positively of how this encourages independence. Staff are currently arranging with their key client holidays for later in the year, the individual needs of the service user are the focus for determining the holiday destination, Portugal and Spain are some of the options being discussed, such opportunities are to be commended. It is recommended that each holiday is risk assessed, monitored and documented accordingly. Within a short walking distance from the home are local shops, and a well known duck pond.Flaxpits HousePage 19 Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The home has an open visitors policy and family contact is encouraged. One service user has regular visits from family, others visit on special occasions. Staff stated that service users are able to receive visitors in their own room, the communal lounges or in the garden.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Care records of daily living and personal statements are service user led. Service users had no restrictions to accessing areas of the home or garden. The manager informed the inspector that service users are able to demonstrate through non verbal communication, their choices to participate or not with daily routines. Relationships, staff spoken with said they had known the service users a long time and therefore roles had developed within the key-working system. The inspector observed staff knocking on service users doors, the interactions with service users was polite, inclusive and encouraged autonomy. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 2 Key findings/Evidence Standard met? Records viewed showed that one service users needs assistance with feeding as he has difficulty swallowing, all staff are able to undertake this task and understand the importance of going at his pace. A risk assessment is in place for one service user who is at risk of choking. One service user was viewed having his breakfast in a relaxed manner. Lunch viewed was homemade leek and potato soup. Menus examined demonstrated choices. However did not contain specific information to demonstrate that service users had access to a nutritious and balanced diet, the menu lacked information in relation to the good practice guidelines in relation to fruit and vegetables, the service users should have five portions per day. The home must maintain a record. The manager said that staff undertake the shopping, service users, on occasion will go shopping with staff for smaller items. Flaxpits House Page 20 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes policies and procedure for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? There are no service users at Flaxpits House require nursing care. The manager gave many examples during the inspection of how service users are supported, these included flexibility and service user choice in when to retire and when to get up. Support for personal and emotional needs are determined by the requirements of the individual.Flaxpits HousePage 21 Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No of service users with pressure sores at the time of inspection (from information taken from care notes) 1X3 Key findings/Evidence Standard met? Information on care files cross referenced with information supplied by the manager in relation to support services for the service users, examples of these are that there is involvement from the community learning disability team, there is a psychologist working with a service user, therapies have been explored for supporting individuals an example of this was hydrotherapy to aid relaxation. During the inspection a physiotherapist was visiting one of the service users, the manager said that it is planned that the physiotherapist will spend time with staff in order to share techniques that staff can use with service users. Every six months a psychiatrist reviews each service users mental health state and their medication, this would be requested sooner if required. Healthcare records were found to be clear and service users are well supported by specialist services. All service users are registered with the local GP and the manager said that service users can access dental, chiropody, and continence care. An optician would visit individuals at the home if this was required. One service user has a high level of falls, the home have explored many areas in relation to this in order to eliminate areas of risk, the service user now wears hip protectors to reduce the likelihood of her individual injuring herself, the risk assessment was not viewed. Other records (accident book, regulation 37 and care sheets) indicated that unusual events were managed appropriately.Flaxpits HousePage 22 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? The Monitored Dosage System (MDS) remains in place at Flaxpits House, this system appears to be effective. All medication held within the home was found to be held in a locked trolley, found to be securely attached to the wall. The home is well supported by the pharmacist who supplies medication for the service users at the home, the home demonstrates effective measures of re-ordering medication and was found to be appropriate, a staff member said that the pharmacist is available to provide advice if required. The home support worker was able to inform the inspector of the policies and procedures in place within the home for the safe administering and handling of medication, this policy was also viewed. Records detailing the administering of medication were found to be accurate, photographs of service users were in place. Stock medication is well audited. No residents within the home self medicate. The support worker was able to inform the inspector of the staff training provided in this area. This process is also recorded on drug competency sheets and incorporates individual explanation of processes to staff by senior management, as well as observation of staff practices.Flaxpits HousePage 23 Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? Not assessed on this occasion.Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of and times-scales for the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days Key findings/Evidence X X X X X X X Standard met? 2Flaxpits HousePage 24 There have been no recorded complaints since the last inspection; it is recommended that the complaints book record actions/outcomes of how complaints are dealt with. The complaints leaflet for the service users is in pictorial form, this is to be commended. During this inspection the Quality Assurance process was discussed. The manager will be taking into account how service users can be involved in this process. A number of staff, were spoken to during this inspection, no complaints or concerns raised. Service users appeared settled and relaxed. No complaints have been received by the NCSC since the last inspection. Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence, or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX2 Key findings/Evidence Standard met? The Aspects and Milestones trust have a written policy and procedure called Do the right thing, this was evidenced in records to have been discussed within staff supervision. The NCSC have received a number of regulation 37 reported incidents within the past six months in relation to one service user who has scratched other service users. The individual displaying this behaviour has complex mental health needs, the manager stated that the situation is monitored closely by staff, staff ensure the vulnerable service user is not left alone in the company of the service user he targets. The inspector viewed a risk assessment in relation to the protection of a vulnerable adult, this must be reviewed on a regular basis, and needs to be dated and signed. South Gloucestershire Social Services Department have allocated an appointee for one service user, this is good practice. Finances are checked on a daily basis and records evidence this, a sample of service users money was examined by the inspector, these were found to be correct. Transport; Service users pay for the homes mini-bus insurance and petrol, a contribution of ten pence per mile is made, records demonstrated this. They also showed that service users personal allowances are being received by the individuals. The service user with his own people carrier has his transport funded by his disability living allowance. An Aspects and Milestones transport policy is in place for transport, although this was not view by the inspector. Flaxpits House Page 25 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Flaxpits House is a purpose built home; the house has a homely nature about it. Accommodation is based on two floors, however not all service users are able to access the upstairs. Leading from the entrance are the two lounges and dining area, there is access to a large well maintained garden from one of the lounges. The house is accessible and has recently fitted handrails at the front of the house in place for those service users with a mobility difficulty. Emergency lighting is in place throughout the house. However records showed that these had not been tested since December 2003. It is an immediate requirement that this is rectified within 24 hours. All areas within the home were clean and odour free.Flaxpits HousePage 26 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. Of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence YES NO NO 6 0 2 0 Standard met? 3 8 0 10 0 0Flaxpits HousePage 27 There is a plan to extend the property to incorporate two extra bedrooms and create an independent unit for one of the service users, he will be funding this extension, some discussion took place surrounding issues this may create, the manager explained that the process was very much in to initial process and she didnt have all of the details, she was going to speak to her line manger to obtain clarification. The NCSC are to be kept informed of the process as a variation in registration may be required, it is recommended that the home pursues the support of an independent advocate for this service user. Maintenance is undertaken on a monthly basis and the home was in a well-maintained state. There were water stained ceiling tiles in the hall (from a bath overspill), some minor paintwork is required on skirting areas, the manger was aware of these issues and is anticipating to incorporate these works with the planned extension, as the extension may take some time the manager should consider the works to be undertaken should the situation change. Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? The inspector viewed all bedrooms, these were found to be reflective of each service users personality and choice, hobbies and interests were reflected in the rooms. In all rooms there were photographs. Rooms contained TVs and music centres. One service user has a time-controlled radio. Two service users have snoozelen equipment in their room. Rooms were clean and odour free. Furnishings were of a good standard, rooms had plenty of storage space. One-service user has a raised bed. The water temperature in one room was excessively hot, the manager was aware and a plumber had been contacted, the manger must re-contact to prioritise, the inspector recommended that a risk assessment be completed for the area. One service users bedroom door was not fully closing, as this is a fire door it was made a requirement that the appropriate contractor be contacted to repair.Flaxpits HousePage 28 Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities, which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The ratio of the bathrooms and toilets to the number of service users was sufficient and all facilities were lockable. The bathroom facilities are homely and clean. Five toilets are available for service users; there is a walk in shower and two bathrooms available. Disability equipment to meet the needs of the service users was in place.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. Key findings/Evidence Standard met? Both floors of Flaxpits House were not accessible to all service users (refer to standard 24). There are two lounge areas within the house, both of which are comfortable and with good furnishings, one lounge area is large and incorporates an open plan dining room, both lounges have access to the garden via patio doors, the garden is large and well established, there is a small summerhouse and a green house has been recently purchased and is awaiting erection. The kitchen is large and has plenty of storage space, one drawer had its front missing, the manager was aware and this was in the maintenance book for repair. Standard 29 (29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? For service users use there is a toilet chair a hi/low bath and two hoists, staff spoken to say that the equipment is adequate for the needs of the service users. There is level access to the communal areas and to the garden. There are handrails on the stairs and also outside the front entrance.Flaxpits HousePage 29 Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home has an infection control policy in place. The home was clean, hygienic and odour free at the time of inspection. The home employs a housekeeper who undertakes kitchen and cleaning responsibilities. There is an industrial washing machine in place; all service users clothes were well laundered. The home has a sluicing area, which is sufficient for the required use.Flaxpits HousePage 30 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? The home has a registered manager in post, who joined Flaxpits House in June 2003, there is a deputy manager and a well-established staff team. The manager has recently introduced allocated duties to each staff member, and records demonstrated that these have been discussed at staff meetings and during supervision, this new system of working ensure staff accountability. The home operates a key working system, staff spoken to were fully aware of their responsibility and spoke well of the system and its benefits. The home also operates a system of working whereby each morning member of staff is allocated to attend to the needs of two service user during their shift, this was also viewed to be working well, service users appeared well cared for.Flaxpits HousePage 31 Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 8 0 0 X 3 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX3 Key findings/Evidence Standard met? The Staff team have a varied range of knowledge and skills; this includes working in a long stay hospital and settling to care in the community. The Manger is currently undertaking the NVQ Assessors award and will then undertake the registered managers award. Three of the care staff group have completed NVQ level 3, the other staff members are at varying stages of completion at levels 2 and 3 in NVQ, another staff member is undertaking a care competency course. The previous inspection report recommended that an NVQ assessor be provided to assist staff with the process, an assessor is now in place, the registered manager is also undertaking this award, this is to be commended.Flaxpits HousePage 32 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. 3 Key findings/Evidence Standard met? Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs and are guided by The Residential Forum assessment. (See standard 32). On duty at the time of the inspection were three care staff and the registered manager. The home operates a system where staff are allocated service users to support during their shift, demonstrating accountability for each staff member. The home operates a flexible rota, which appears to work well, the manager has also introduced an annual leave plan for staff. Service users appeared well supported during the inspection. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Human resources folder viewed during the inspection, this contained the trusts equal opportunities policy. All staff undertake a six months probationary procedure, this is linked to their induction. Staff records including CRB clearance, two references, proof of identity, staff statement of terms and conditions, are all held at the main Aspects and Milestones head office. It is a requirement that these records be held at Flaxpits House, by April 2004, as detailed in Schedule 2, Regulation 7,9,19. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 Key findings/Evidence Standard met? Staff training records viewed by the inspector found that not all staff have undertaken five paid days training per year, standard 35.5, it was also noted that three staff members have not undertaken any training since 2002, it is a recommendation that this training is undertaken in order to ensure staff competency and to maintain staff skills, it is acknowledged by the inspector that night staff and staff approaching retirement are reluctant to undertake training, however it is the managers responsibility to look at strategies to overcome this. It was noted that one staff member is completing a care competency training course and this is to be commended, other training courses which have been fairly recently undertaken have included sexuality workshops, bereavement and loss, manual handling and continence care. Training records did not reflect the homes commitment to training, it was noted that the manger is addressing training within staff supervision and training.Flaxpits HousePage 33 Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 4 Key findings/Evidence Standard met? Supervision records in place were of a high standard, it was evident that supervision is undertaken on a regular basis and that staff are well supported by the manager, discussion topics during supervision include key worker issues, individual responsibility, training and development needs and issues of concern. It was evident in these records that the process was an effective one, staff confirmed that supervision is undertaken on a regular basis. The registered manager receives supervision and participates in senior management meetings on a monthly basis.Flaxpits HousePage 34 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care or equivalent. YES3 Key findings/Evidence Standard met? The registered manager has been in post at Flaxpits House since June 2003, prior to this she has been in management roles since 1995, the manager has a Certificate in Social Care, City & Guilds in management, 325.2/3, she is currently in the process of achieving the A1 & A2 NVQ Assessors award and also the Registered Managers Award. The Registered Manager has been deemed a Fit Person and has been interviewed by the NCSC. Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Throughout the inspection it was evident that the manager has a commitment to a person centred approach to care and support. The manager was positive and motivated through the inspection process her approach to staffing was one of trying to develop staff skills and to offer guidance where required. Staff appear well motivated to provide a good service.Flaxpits HousePage 35 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems based on seeking the views of service users are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 2 Key findings/Evidence Standard met? The inspector observed staff seeking feedback from service users as to their choices and opinions. Visits by the registered provider are being conducted on a regular basis and these are recorded. There has been no change in the Quality Assurance process since the last inspection, however it was positive to see that the manager is going to undertake a Quality Assurance Audit, as part of the registered managers award. This audit will cover many areas such as records, staff training and development, it was recommended by the inspector that service users are involved in the audit process and their views are obtained and recorded. Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Younger Adults. 3 Key findings/Evidence Standard met? A comprehensive policies and procedure file was in place that was available to staff, this file included such policies as: Equal Opportunities, Grievance Procedure, Harassment Policy, Data Protection Act, Do the right thing Policy, it was evident from records that these polices and procedures are discussed with staff during supervision and appraisal processes.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained up to date and accurate. 2 Key findings/Evidence Standard met? A risk assessment was in place for a service user who is deemed at risk if left alone with another service user, this was found to contain detailed information, however it had not been signed and dated, it is recommended that this is undertaken to monitor the wellbeing of the service user who is deemed at risk. An Aspects & Milestones policy Do the right thing is in place.Flaxpits HousePage 36 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The inspector viewed the fire panel and this was found to in working order, break glass points and smoke detectors were in place, fire extinguishers were in place. It was observed that a service users bedroom door was not shutting fully, during the inspection the manager contacted the contractor to visit to deal with immediately. It was also noted that the water temperature in a service users bedroom was excessively hot; the manager had already contacted a plumber to visit. Portable Appliance Testing on electrical appliances was undertaken in 2003. Radiator covers in place. The inspector viewed a number of records during this visit these included the fire logbook, which detailed when staff training took place, A fire drill had not been undertaken since 16.09.02, it was therefore made an immediate requirement that this be undertaken within the next 24 hours. Emergency lighting should be tested on a six monthly basis, this had not been undertaken since December 2003, and it was made an immediate requirement that the lighting be tested within the next 24 hours. Standard 43 (43.1 ­ 43.7) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met? Certificate of Public Liability Insurance on display. Regulation 26 visits are undertaken on a monthly basis, these visits evidence that quality assurance, financial planning, staffing resources and training were considered on a regular basis.Flaxpits HousePage 37 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateOdette Coveney Paula Cordell Michael Miles 2nd July 2004Signature Signature SignatureFlaxpits HousePage 38 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Flaxpits HousePage 39 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this draft report relating to the Unannounced Inspection conducted on 10th February 2004 of inspection at Flaxpits and any factual inaccuracies: Please limit your comments to one side of A4 if possible No response receivedAction taken by the NCSC in response to provider comments: Flaxpits House Page 40 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by 31st March 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNONOYESOther: enter details here NOFlaxpits HousePage 41 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I for Aspects and Milestones Trust and Flaxpits House confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I for Aspects and Milestones Trust and Flaxpits House am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Flaxpits HousePage 42 - 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. 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