CARE HOME ADULTS 18-65
Flaxpits House 74 Flaxpits Lane Winterbourne South Glos BS36 1LB Lead Inspector
Odette Coveney Unannounced Inspection 12th January 2006 09:30 Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Flaxpits House Address 74 Flaxpits Lane Winterbourne South Glos BS36 1LB 01454 776191 0117 9709301 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) admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Miss Dionne Marie Brown Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8), Physical disability (8), of places Physical disability over 65 years of age (8) Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Male and Female 35-64 years and 65 years and over Date of last inspection 29th June 2005 Brief Description of the Service: 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 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. 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. At the time of the inspection builders were on site completing an extension to the property, this includes a one-bedded bungalow and an additional two bedrooms and one bathroom. The plans also include making four of the bedrooms en-suite. The registered manger is Dionne Browne, who has been in post since June 2003. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process to examine the care provided, and to monitor standards being maintained at the home in relation to the ten requirements and the four recommendations from the last inspection that was conducted in June 2005. The inspection took place over one day with two inspectors. During the process two residents and four staff were spoken with. The manager was not present during the inspection; staff members on duty were engaging in the inspection process, were informative and interacted well with each other and the clients. The inspectors looked around the building and a number of records were examined. What the service does well: What has improved since the last inspection?
The environment for those living at Flaxpits House will be improved when the current building works have been completed. Following the last inspection the home forwarded a completed variation of premises application. An extension to the original building has created three new rooms for clients with en-suite facilities, an original bedroom has been extended with an en-suite and ceiling tracking being installed. A one-bedroom bungalow has also been built and is attached to the extension. These works makes for purpose-built facilities and an improved area of the home for individuals to live. A requirement was made at the last inspection that in order to ensure clients safety and protection the home must complete a risk assessment in relation to the appropriate administration and use of rectal diazepam and that this use must be recorded on individuals care plans. Staff spoken with said that the client no longer requires this medication. The home are reminded that should this method of medication administration be required the appropriate documentation must be completed. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 6 Those living and working at Flaxpits House are confident that information held is correct now that the organisation changed the headings on the organisations policies and procedures as they now reflect the current status of the Trust. What they could do better:
At both previous inspections, most of the requirements and recommendations made at previous inspections had not been met. There have been no significant areas of improvement with a further eleven requirements and four recommendations being made at this inspection. It was required at the last two inspections that each individual had in place a copy of the terms and conditions of their placement. As the manager was not on site at this inspection these documents were unavailable and therefore will be again reviewed at the next inspection. Staff were not aware of any changes to these documents. Clients would be better supported and empowered to make choices on how they choose to spend their leisure activities if action plans incorporated the use of pictures and photographs. To effectively meet the needs of client’s individuals care plans must be reviewed on a monthly basis and must include all aspects of individuals needs. The care plan must indicate that all areas of the plan have been revaluated and changes recorded. In order to fully demonstrate that individuals are supported with identified health needs it is required that the home must ensure that clear evidence and information is in place to show that the health care needs of individuals are being met. To ensure that the information held within individuals care documentation is up to date and relevant it is recommended that individual’s personal information sheets are reviewed and that consideration is given to the review of the order and contents contained within individuals care plans. Those living at the home would be safer if staff received medication competency training, this was required at the previous inspection. There are no qualified staff members at the home and therefore staff have not received training by a competent person. It is also required that stock held medication be better recorded. In order to ensure that individuals are safe the home must ensure that risk assessments are reviewed and updated where required to ensure that the information held is accurate and current and that the assessments encompass all areas of individual’s lifestyle, assessments must include aspect of manual handling, also the CSCI must be notified of any incidents that affect the wellbeing of those living at the home. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 7 Those living at the home would be assured that their wishes and their choices in the event of their death are acted upon if the home sought methods to obtain these and these wishes were recorded. Clients property and valuables would be safer if these were recorded on an up to date inventory and if these were reviewed on a regular basis. The home would be a better, more hygienic and a safer environment for individual’s to live in and for the staff who support them if areas of the house were better maintained. Staff practice must change in respect of supporting a resident in an unhygienic and undignified manner. The sluice should be cleared of storage, toilet roll must be available in all toilet areas, the water damaged ceiling tiles should be repainted or replaced, the small lounge area requires the ceiling to be repainted and the wall to be given attention/repair, the carpet in this individual’s room must be cleaned and the boiler room needs to be cleared of clutter. Staff must receive sufficient fire safety instruction and the emergency lighting needs to be checked on a monthly basis. It was identified at this and two previous inspections that the home does not have in place an effective quality audit system based on seeking the views of the clients. 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. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 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 Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Prospective clients to the home can be assured that their needs will be assessed, however information for prospective clients is in need of updating. There are no contractual arrangements in place between the organisation and those living at the home. EVIDENCE: There are no vacancies at the home and there have not been any for some time. Evidence was in place at the home to show that the last individual admitted to the home had been supported appropriately with information being provided from their previous placement on their likes and dislikes. The home had in place compatibility and suitability assessment, which recorded how the individual interacted with others living at the home, potential areas of health and safety and recorded, identified needs. Contractual arrangements were in place between the contracting, placing authority and the home. It has been required at the last two inspections that each individual had in place a copy of the terms and conditions of their placement, as the manager was not on site at this inspection these documents were unavailable and therefore will be again reviewed at the next inspection. It
Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 10 is essential that the registered manager develops and agrees these contracts with individuals living at the home in order that they have a written and costed/statement of the terms and conditions between the home and the individual which outline the rights and responsibilities of all parties involved. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8, 9 Individuals assessed and changing needs are not fully reflected in care plans. Records of risk assessments must be improved. EVIDENCE: Those living at Flaxpits House have complex needs with some physical impairments and learning disabilities. The home has a wealth of information that is contained within individuals care plan documentation. It was clear that this had been gathered over a long period of time. One individual had records dating back to 1999. It is recommended that consideration is given to the review of the folders’ contents and their order are reviewed as this will make the information in place more accessible with relevant up to date documents in place. A number of individuals care plan information was reviewed at the inspection. Information in place covered areas such as personal care, healthcare needs, personal, emotional and individual’s communication areas of support required to maintain their level of independence. It was found that one individual’s care plan had not been reviewed since April 05, another in July 2005 yet both of
Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 12 these individuals had significant area of support needs which had not been incorporated within the care plan with no specific guidance to direct and guide staff practice. It is required, as it was at the last inspection, that individuals care plans must be reviewed a minimum of every six months, or sooner should needs change. Care plans must fully document that all areas of the individual’s needs have been fully evaluated, with identification of how these needs will be met. One of the staff members was fully conversant with an individual’s specific afternoon routine, and specialist areas of the individual’s healthcare, yet these had not been recorded on the care plan with no information provided to ensure continuity of care and service provision for the individual. Information seen in individuals personal information sheet had not been reviewed or updated for some time. As this record contains contact details of next of kin and significant others it is recommended that these be reviewed in order to ensure that the information recorded is still correct. Two requirements in respect of areas of risk assessment were made at the previous inspection. This documentation was reviewed at the inspection. The organisation has developed a policy and procedure in respect of service user’s holidays, this coupled with information seen at the home demonstrated that this aspect of individual’s life had been fully evaluated and appropriately risk assessed. The other requirement that individuals risk assessments must be reviewed and updated when required has not been met. One individual’s assessments had not been reviewed since April 2005; other individuals did not have assessments in place in areas such as pressure area care, the use of bedsides, the use of monitors and the use of a temporary alarm on a bedroom door. This must be in place to evidence that individuals are being supported appropriately. A further requirement in respect of manual handling was made at this inspection, examination of these records showed that one resident had no assessment in place; another individual’s assessment had not been reviewed or updated since 2001. These must be in place to ensure that individuals are moved/assisted in a safe manner. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13, 14, 17 Individuals have opportunities for personal development, to access the community and engage in appropriate activities. Individuals are offered a healthy diet. EVIDENCE: It was recommended at the last inspection that clients would be better supported and empowered to make choices on how they choose to spend their leisure activities if action plans incorporated the use of pictures and photographs. No evidence was in place to show that this had been implemented. Those who are able, have opportunities to use practical life skills the inspector saw on care documentation that some clients make snacks and drinks, go shopping for personal items and go out for lunch. At the time of the inspection one of the clients went out with day care support, another went out shopping another two clients went out for lunch with staff from the home.
Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 14 Records and also the observations of the inspector during the inspection demonstrated that individual’s are supported and given the opportunity to participate in community based activities which include trips out to church, pubs, hydrotherapy, and trips to the theatre, bowling and places of local interest. One of the staff members spoke of the job satisfaction they obtained by spending one to one time out of the home with their key client supporting them to partake in activities of their choosing. One of the clients at the home is going on holiday to Spain next week. Records showed that clients are supported and encouraged to maintain relationships with family and friends. Information seen in the visitor’s book showed that there are a number of visitors to the home. The kitchen was seen to be clean and tidy with items in the fridge and freezer appropriately labelled. Lunch had been tailored to the specific preferences of the clients and staff were observed asking individuals what they would like. Three different meals were provided at lunchtime. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Individuals are supported appropriately with their personal support however there is insufficient record keeping in place to fully demonstrate that individual’s healthcare, medication and end of life choices are being met. EVIDENCE: A number of individuals care plan documentation were examined during the inspection, records examined included; Personal information sheets, care plans, risk assessments, daily diary sheets, weight charts, records of health and professional support, correspondences from health professionals, review meeting minutes. Upon examination of these records it was clear that there was not sufficient information recorded to show that the healthcare needs of individuals are being fully met. Examples include special dietary and pressure care needs; outcomes of test results and no evidence of follow up from staff observations of healthcare concerns of individuals. During the review of individuals records, which included care plan review meetings, correspondence from health professionals and daily records maintained at the home by staff it was evident that identified healthcare needs of individuals had not been met. A requirement was made that the home must ensure that the healthcare needs of individuals are met with appropriate contact to be made to the relevant professionals. Staff confirmed that
Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 16 individuals were supported with their primary healthcare needs such as chiropody, opticians, dentist and vaccinations however this was not clear within records held at the home. The home are required to ensure that the healthcare records of individuals are maintained to demonstrate fully that individuals are able to access primary healthcare services. It was noted at the last inspection that staff have not received medication competency training from a qualified person. In order to ensure that systems of medication administration are safe. Staff spoken with confirmed that they have not received any training by a qualified person in this area. The requirement remains. Medication systems of administration, recording and storage were reviewed at the inspection. Cough medicine was in the cabinet yet there was no record of this being in the home. It is required that stock held medication must correspond with records held at the home in order to demonstrate that these are audited and are able to be accounted for. It is also recommended that excess medication should be returned to the pharmacist and only stock required should be maintained at the home. A requirement was made at the last inspection that in order to ensure clients safety and protection the home must complete a risk assessment in relation to the appropriate administration and use of rectal diazepam and that this use must be recorded on individuals care plans. Staff spoken with said that this medication is no longer required by the client and is not used on the home. Records of medication returned to the pharmacist and medication records maintained at the home confirmed that this medication was no longer in use. A recommendation was made at the previous three inspections that individual’s wishes in the event of their death are sought and recorded. At the last inspection the inspector saw that the home had implemented a funeral plan for one of the clients who has been identified by health professionals as in receipt of terminal care at the home. No other progress has been made in obtaining the choices and views of the others living at the home. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 There are clear guidelines, policies and procedures in place to ensure that individuals are protected from abuse and staff have demonstrated a clear understanding in this area. EVIDENCE: Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 18 Due to some individuals being unable to complain verbally the inspector asked a staff member how would she know if a client wanted to make a complaint, they replied that staff observe individuals behaviour as an indication of satisfaction and should any client appear to be dissatisfied then staff would try a different approach, any changes in behaviour are monitored and recorded. The Commission for Social Care Inspection have not received any complaints in relation to the service provided at the home. A copy of the organisation’s complaints procedure was in place in each of the individuals care files, these had been produced in pictorial format and contained clear information in order to guide individuals through the complaints process and outlined what support they would be given and what happens when you make a complaint. The home has policies in place for the Protection of Vulnerable Adults and The Trust has in place a ‘Do the Right Thing Policy’; the inspector viewed these. Care records demonstrated that staff are very aware of the protection of vulnerable adults and upon discussion with a staff member it was evident that the team have a clear understanding of their roles and responsibilities. Members of the staff team have undertaken the protection of vulnerable adults training. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29, 30 The extension to the property has improved the facilities for individuals who will use this area however other improvements in respect of the rest of the environment and infection control are required. EVIDENCE: The home is situated in a residential area in Winterbourne. It is located within walking distance of the local shops, public houses, banks and also local churches; there are bus stops within a short walking distance, which can take you into Bristol City Centre. The home is also within a short distance of the Avon ring road. A requirement was made at the last inspection that the home must complete an application to the Commission for the variation to the property and to increase the bed numbers from 8 to 10. This was received and the building works are nearly complete. A site visit was taken to the home in October by the inspector to monitor progress. The new extension is purpose built with ensuite facilities with access to the main house and the garden. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 20 A requirement was made at the previous inspection that toilet; soap and hand towels are available for individuals use. Most toilet areas had these items in place however one toilet had no toilet roll in place and therefore this requirement will remain and will again be reviewed at the next inspection. At this inspection two requirements in respect of hygiene and infection control were made. One was that the home must provide a urinal for an individuals use, that buckets of disinfectant used in toilet areas be removed and the appropriate sluice area must be used. It was noted at the last inspection that the sluice room was being used as a storeroom and it was recommended that this room be cleared of excess rubbish, this has not been undertaken. It was also noted at the last inspection that in order to maintain a homely environment for the clients it was recommended that attention was paid to the following areas: The water damaged ceiling tile on the ground floor be replaced or re-painted, this had not been undertaken and following a recent flood in the same area further damage is now evident. It was also recommended that the ceiling required repainting and that attention/repair should to be given to the wall in the small lounge area (currently being used as a temporary clients bedroom), the carpet in this same room must be clean or replaced if the stains evident are unable to be removed. None of this has been undertaken. In order that the Trust can demonstrate that it is committed to maintaining the fabric of the building it is again recommended that these works be undertaken. A tour of the building found that the boiler room was being used as a storage area for equipment being used by the builders on site, this constitutes a safety hazard and it is required that this room is cleared. It is further required that the identified maintenance within the home must be undertaken to keep the home in a good state of repair. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 Staff are aware of their role and responsibilities. Records of training are in need of improving. EVIDENCE: Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs of the individual’s. The staff team have a varied range of knowledge and skills, they were observed by the inspector to be good listeners, effective communicators and were interested and motivated in meeting the needs of those living at the home. The inspector viewed the staff training records and found that staff have received regular appropriate training. Training attended within the past few months has included; manual handling, first aid, and epilepsy awareness. It is recommended that staff training records be updated in order to fully reflect the actual training, which has been undertaken by staff as certificates were in place to evidence staff had completed the training yet this had not been recorded on their individual record. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 39, 40, 42 The Trust have clear processes, policies and procedures are in place to demonstrate the self-monitoring, review and development of the organisation however clients views are not in place to underpin these. Fire safety in the home must be improved. EVIDENCE: The registered manager Dionne Browne was not present during this inspection. Ms Brown has worked in the Trust for a number of years and has extensive experience within the field of learning disabilities. Some staff members spoken with raised some concerns to the inspectors over how unapproachable Ms Browne has been when issues have been raised with her, staff said that they are not consulted and are not kept informed of issues within the home to ensure continuity of care. Staff also said that clear channels of communication were not in place at the home. The inspector raised these issues with Ian Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 23 Knowles on 13th January with a subsequent letter on 31st January to enquire how these concerns will be followed up. The inspector viewed the organisational policies and procedures in place at the home, these are robust and provide sufficient information in order to direct and guide staff practice. The policies seen were appropriate to the service provided at the home. It was recommended at the last inspection that the Trust review and update the headings on their policies and procedures documents. A review of these found that this had been undertaken, the Trust have changed the headings on the organisations policies and procedures and they now reflect the current status of the trust. The Trust have clear systems in place to show that they undertake a full and comprehensive audit review of the services within their organisation and produce an annual report which is made available to the public. It was identified at this and both previous inspections that the home does not have in place an effective quality audit system based on seeking the views of the clients. Following an inspection undertaken in December 2004 the inspector forwarded to the manager information that may have provided some assistance in this area, however still no significant progress to seek the views and wishes of those living at the home has been made. It was noted at the last inspection that the home has sought the views of professionals however there was no information in place to show what had happened as a result of this information being obtained. It was found at two of the previous inspections that client’s inventories had not been updated for some time. Some clients had no inventories in place; it was recommended that these records be updated in order to reflect correct information on individuals. It was recorded in the last inspection report that there has been no attempts to rectify this the recommendation remains and will again be examined at the next inspection. It is important that individual’s possessions are recorded to ensure that all items are clearly accounted for. It is required at both this and the previous inspection it was required that staff must receive sufficient fire safety instruction. The inspector was concerned to find again at this inspection that staff have not received sufficient fire safety instruction. It is required that night staff must receive instruction every three months and other staff must receive instruction every six months. The fire logbook was viewed and on the whole the home were undertaking the appropriate weekly and monthly checks, however the emergency lighting had not been checked since October 2005. It is required that emergency lighting must be checked every month. Upon discussion with staff, examination of records and a tour of the building it became evident that there were three incidences in which the Commission should have been notified, the home are required to inform the Commission
Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 24 who must be notified of any event in the home which adversely affects the well-being or safety of any service user. Accident reports seen at the home demonstrated that incidences had been dealt with appropriately with individuals receiving the required support. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 2 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 1 25 2 26 X 27 X 28 3 29 2 30 2 STAFFING Standard No Score 31 3 32 X 33 X 34 X 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X 3 1 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 1 1 X 2 2 3 2 1 X Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. 6. 7. 8. Standard YA9 YA42 YA42 YA6 YA19 YA30 YA19 YA39 Regulation 13(4)b 23(4) c 23(4)b 15 13(1)b 13(3) 17(1)a 24 Requirement Individuals risk assessments to be reviewed and updated where required. Emergency Lighting must be checked every month. All staff to receive sufficient fire instruction. Individuals care plans to be updated and reviewed. The home must ensure the healthcare needs are met. Toilet roll, soap and hand towels to be available for individuals use. Healthcare records must be maintained. Develop an effective Quality Assurance monitoring system based on seeking the views of clients. It is required that each individual has a copy of the terms & conditions between the home and the client. Staff that administer medication must undertake competency training by an accredited trainer. Manual handling assessments must be completed. Identified risks at the home must
DS0000003383.V273670.R01.S.doc Timescale for action 12/03/06 12/02/06 12/03/06 12/03/06 12/02/06 12/01/06 12/02/06 12/04/06 9. YA5 4&5 12/03/06 10. 11. 12. YA20 YA9 YA9 13(2) 13(5) 4 (c) 12/04/06 12/02/06 12/02/06
Page 27 Flaxpits House Version 5.1 be recorded and assessed. 13. 14. 15. 16. 17. 18. YA24 YA42 YA24 YA30 YA20 YA24 13(4)a 37 13 (3) 12(1) a 13(1) 2 23(2)b Boiler room to be cleared of clutter. CSCI must be notified of incidents, which affect those living at the home. Carpet in individuals room to be cleaned or replaced if stains cannot be removed. Urininal must be provided for an individual’s use. Stock medication must tally with records held. Identified areas of maintenance within the home must be undertaken. 30/01/06 12/01/06 12/02/06 12/02/06 12/02/06 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard YA11 YA35 YA41 YA21 YA20 YA6 YA6 Good Practice Recommendations Client’s action plans should contain photographs or pictures in order to enable individuals to make choices. Staff training records to be updated. Individual’s inventories must be updated. The home should seek methods of obtaining the views of individuals in the event of their death, these must be recorded. Excess medication to be returned to the pharmacist. Consideration should be given to a review of individuals care files. Personal information sheets to be updated. Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Flaxpits House DS0000003383.V273670.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
