CARE HOME ADULTS 18-65
Flaxpits House 74 Flaxpits Lane Winterbourne South Glos BS36 1LB Lead Inspector
Odette Coveney Announced 29 June 2005 09:30 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 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 Stationary 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 D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Flaxpits House Address 74 Flaxpits Lane Winterbourne South Glos BS36 1LB 01454 776191 0117 9709301 admin@aspectsandmilestones.org.uk Aspects & Milestones Trust Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Miss Dionne Marie Brown Care Home for Younger Adults 8 Category(ies) of PD Physical disability for 8 registration, with number PD(E) Physical dis - over 65 for 8 of places LD Learning disability for 8 LD(E) Learning dis - over 65 for 8 Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Male and Female 35-64 years and 65 years and over Date of last inspection 20th December 2004 Unannounced 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. There are plans for an extension to the property, these include a one-bedded bungalow and an additional two bedrooms and one bathroom. The plans also include making four of the existing bedrooms en-suite. The manager was reminded that the Commission for Social Care Inspection is to be kept informed of the process, a second application in order to apply for a variation of premises has been forwarded to the registered manager for completion. The registered manger is Dionne Browne, who has been in post since June 2003
Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection conducted as part of the annual inspection process to examine the care provided, and monitor the progress in relation to the five requirements and nine recommendations from the last inspection that was conducted in December 2004. The inspection took place over seven hours. During the process two clients, four staff, the registered manager and a representative from the workers education association who was visiting the home were spoken with. The inspector looked around some of the building and a number of records were examined. Following consultation with the manager and the staff team it was agreed that those living at the home would prefer to be referred to as clients within the inspection report, rather than service user and therefore this has been reflected within this report. The Commission for Social Care Inspection has produced a leaflet for those living in care establishments entitled ‘Is the care you need the care you get?’; a copy of this was left at the home to be put on the home’s notice board. The inspector also shared with the home information that the Commission has produced in a picture format providing information for those living at a care home as to what work the Commission does, also given were comment cards for individuals produced with pictures in order that individuals can comment on the service and levels of care provided at the home. What the service does well:
The home provides a high level of service at the home that is delivered in a person centred way for those who have complex needs. Through discussion with management, observations of those living at Flaxpits House, the staff and a review of care file information, it was evident that appropriate care and support was provided for those living at the home. Services provided within the home and externally have been undertaken in an individualised and person centred way. Those living at the home have a stimulating and varied life at the home of their own choosing. Personal development and growth are encouraged, various informal activities made available and provision of care is tailored to the specific wishes and choices of individuals, relationships between individuals and staff are well established and effective methods of communication both verbal and non verbal have been developed.
Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better:
Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 7 At this inspection six requirements and five recommendations were made; upon examination of records and the evidence seen in place, it was found from the previous inspection that two of the five requirements had been met and also four of the nine recommendations were met, one was ongoing and no progress had been made with the remaining four recommendations. To effectively meet the needs of client’s individuals care plans must be reviewed on a monthly basis and the summary of the care plan must indicate that all areas of the plan have been revaluated and changes recorded. Clients would be supported within a safer environment and staff would be better equipped to deal with potential emergency fire situations if all staff received sufficient fire safety instruction. 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. To ensure clients safety and protection the home must complete a risk assessment in relation to the appropriate administration and use of rectal diazepam, this use must be recorded on individuals care plans. In order to ensure all aspects of the client’s safety and to avoid potential risks without limiting the enjoyment for the resident’s the home must expand upon the current risk assessment in order to cover all aspects of client’s holidays. Clients would be better protected and staff awareness would be raised if staff undertook medication competency training. Clients would have more awareness of their rights and of the organisations responsibilities of the placement if individual contracts of terms and conditions were in place and were produced in a communication format most appropriate to the needs of the individuals and their level of understanding; this requirement has been in place at the previous two inspections and action must be taken by the home to implement these. 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 photograghs and also if the home developed a method of seeking the views and wishes of individuals as part of a quality audit tool, in order that these can be acted upon. The environment for those living at the home would be better maintained if consideration was given to re-painting the corridor skirting and doors, if the small lounge area were redecorated, the water ceiling stain on the ground floor ceiling was repainted and also if the ground floor sluice area was cleared of unnecessary clutter.
Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 8 In order to ensure that the proposed building works/extension to the property do not have a detrimental effect on those living at the home and that the proposed works comply with the National Minimum Standards the organisation must complete an application for variation of premises. Those living at the home would be assured that their wishes and their requirements in the event of their death are acted upon if the home sought methods to obtain these and these wishes were recorded. Those living at the home would be safer if staff received medication competency training, this was recommended at the previous inspection, there are no qualified staff members at the home and therefore staff have not received training by a competent person. Those living at the home would be supported in an environment where up to date policies and procedures are in place, and staff would be confident that the information held is correct if the organisation updated and reviewed these documents and changed the headings on these in order that they reflect the current status of the trust. Clients property and valuables would be safer if these were recorded on an up to date inventory of their effects and if these were reviewed on a regular basis. 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 D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 9 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 Standards Statutory Requirements Identified During the Inspection Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 3, 5 Clients do not have information on their rights and the responsibilities of the organisation. Contract arrangements require improvement. EVIDENCE: There are currently no vacancies at the home and there have not been for some time. Comprehensive care management and health need assessments were seen on file. The home has developed comprehensive care plans from the information provided by the observation of clients, information from carers and also information gathered during the assessment process and during the trial period and continues as part of an ongoing assessment process. In place were also the purchasing arrangements made between the placing local authority and the home. In place at the home are documents called licence agreements, which still referred to the previous organisation. The documents in place are outdated and do not contain sufficient information. The requirement was made at the two previous inspections that the organisation should develop and agree a written and costed contract/statement of terms and conditions between the home and the client and this should be produced in a format appropriate to each individuals needs. Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 11 Due to the proposed building works and the changes in the staff team it was clear that the statement of purpose for the home will be changing, as will the home’s service users guide, these will be reviewed at the next inspection. Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 6, 7, 8, 9 The healthcare and medication needs of clients are well met and relationships between residents and staff are well established with other needs and choices being met. EVIDENCE: Those living at Flaxpits House have complex needs with varying impairments and learning disabilities. Support, skill and understanding is required from the staff team in areas of communication, promoting individuality and an understanding of the varying impairments associated with a learning disability. Staff spoken with during the inspection were able to provide an in depth understanding which has been developed through time, patience and relationship building. Risk assessments for four of the individuals sampled had not been reviewed or updated for some time, it is required that individuals risk assessments are evaluated on a regular basis in order to ensure that the information held is accurate and sufficient. Care plans for four clients had not been reviewed, it is essential that these documents are reviewed and updated where required in order to fully reflect
Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 13 the needs and wishes of individuals and that full information is provided in order to direct and guide staff to support the individual. The inspector had contact with three of the clients who indicated that they were happy in the home and demonstrated a degree of confidence when communicating with staff at the home. The atmosphere at the home was calm and relaxed. Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 11, 12, 13, 14, 16 The clients are encouraged and supported to participate in activities of their choice. Competent staff promote and foster interest in new ventures in the community. EVIDENCE: Information seen by the inspector, and confirmed by staff and client action plans showed that those living at the home are offered a variety of social activities. Clients are able to participate or not, this is dependent on the individual’s choice. At the time of the inspection clients were participating in a number of activities of their choosing, these included being on holiday, going out for breakfast and being supported on a one to one basis in the home by a staff member from the workers education association. Staff from this organisation told the inspector how individuals have benefited from continuity of service at a level and a pace appropriate to them, that they have supported individuals with baking, arts and crafts and also activities out of the home. On the day of the inspection this person was attending a meeting with the manager of the home reviewing the effectiveness of this service for those living at the home, this staff member told
Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 15 the inspector that staff at the home are always motivated to support clients and are interested in what they are doing and strive to provide continuity and maintenance of individuals skills. Information seen in daily records evidenced that clients regularly take part in the following activities; hydrotherapy, shopping, music groups, visiting places of local and personal interest, shopping. It is recommended that in order to improve client’s choice and enable effective communication individual’s action plans should be produced in pictoral/photogragph format. Staff spoken with told the inspector that activities and social arrangements for individuals had improved significantly since the last inspection. At the time of the inspection two clients were on holiday in Whitby, other holidays this year have included Portugal and Devon. The inspector saw that some of the individuals had in place a holiday risk assessment which covered areas such as individuals mobility, however these documents require more information in order to ensure that individuals activities are not limited and appropriate actions are undertaken to ensure individuals safety. The clients moved confidently around the home and indicated through verbal and non-verbal communication that their needs were being met. Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 18, 19, 20, 21 The personal and healthcare needs of the clients are monitored effectively and action is taken promptly when concerns arise, so that clients can be confident that their needs will be met. Some progress has been made to seek the wishes of individuals in the event of their death. EVIDENCE: A review of a clients care file provided evidence that the home had made strenuous efforts to consult with health professionals to ensure that their palliative care is reviewed on a regular basis and that the appropriate guidance is sought and relevant support provided. Information reviewed demonstrated that a multi disciplinary approach is taken. This is consistent with good practice. Comment cards received from visiting professionals indicated good communication with the home and commented on the high level of commitment from the staff team. There was evidence that staff members have received training in health related issues for example ‘first aid’ and ‘all behaviour is meaningful’. Staff members told the inspector of the recent training they had received in relation to epilepsy awareness, that they had been taught practical skills on how to administer rectal diazepam, which is required for one client when they are ‘in
Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 17 status’. Clear information was in place in relation to when this medication is to be administered, however there was no risk assessment in place in order to ensure the safety of the individual and their protection. Systems for administration of medication are good with clear and comprehensive arrangements in place to ensure that clients medication needs are met, however staff have not received medication competency training from a qualified person. In order to ensure that systems of medication administration are safe it is required that staff undertake medication competency training. A recommendation was made at the previous two inspections that individual’s wishes in the event of their death are sought and recorded. At this inspection the inspector saw that the home have 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. Staff members demonstrated throughout the inspection process a sensitive, committed and enthusiastic approach to their role within the home. The clients were clearly comfortable and at ease. Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 18 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 standard(s) 22, 23 The complaints process in the home is good and there was evidence that client’s views are listened to and acted upon. The risk of residents suffering from any form of abuse or neglect is appropriately minimised. EVIDENCE: Policies and procedures are in place to safeguard the clients from any form of abuse. The manger provided a clear example of how staff actions, which have not been appropriate, have been handled in order to ensure the protection of those living at the home. Two staff members spoken with demonstrated a good understanding of their role in relation to the protection of the clients, and were very clear about reporting any concerns or issues in relation to bad practice. No complaints have been received by either the home or the Commission for Social Care Inspection. No clients at the home are on the protection of vulnerable adults list. No areas of concern were recorded on care documentation. The inspector saw that contained within each individuals care records is a pictoral copy of the organisations complaints procedure containing clear information on how individuals would be supported should they wish to make a complaint. Due to the limited communication skills of those living at the home two staff members were asked to explain how they would know if individuals were unhappy or wanted to make a complaint, both staff members demonstrated a
Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 19 sound understanding of the interpretation of individuals expressions and body language and stated the importance of recording information and reporting any concerns or issues they may have to ensure that individuals needs are acted upon. During the inspection staff were observed auditing individual’s personal monies held for safekeeping by the home, this is done on a daily basis and records for this were seen to be well maintained. Financial systems are audited by external auditors on an annual basis. Staff were fully conversant with their role and responsibility in this area. Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 20 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 standard(s) 24, 25, 26, 27, 28, 29, 30 The home is well managed and safe and the quality of furnishings and fittings in the home is good, providing a warm comfortable and homely environment ensuring individuals needs are met. EVIDENCE: The home is situated within a short walking distance of Winterbourne High Street and is close to many local amenities such as shops, a bank, hairdresser and a local duck pond. The home has it’s own transport which is a great asset and is often used on a daily basis. There are plans for an extension to the property, these include a one-bedded bungalow and an additional two bedrooms and one bathroom. The plans also include making two of the existing bedrooms en-suite. The manager said that ‘tracking’ will be fitted in one of the individual’s rooms once the building works have been completed in order to support an individual with their manual handling requirements. The inspector has previously received confirmation from the manager that the proposals will be funded by the Trust and not by funds from those living at the home. The manager was reminded that the Commission for Social Care Inspection is to be kept informed of the proposed building works that are planned for commencement in August 2005. The
Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 21 inspector forwarded an application to apply for a variation of premises to the area manager in December 2004, this has not been completed and returned the manager was reminded of the importance of the completion of this document and another application was forwarded on June 30th 2005. Since the last inspection the home has taken out an unused shower facility and this has been replaced by a new hi/low bath, both the manger and staff spoken with said that the clients have benefited from this new aid and enjoy use of this facility. There are a number of toilet, washing and bathing facilities provided at the home that are available for clients use, these are within close proximately to residents private accommodation. The number of facilities available are sufficient for the numbers of clients accommodated at the home. It was found at this inspection that both an upstairs and downstairs toilet area had no toilet paper, soap or hand towel’s, the manager and a staff member told the inspector that these are not in place due to one client inappropriately disposing of these items, it is not acceptable that the behaviour of one individual impacts on the hygiene of others living at the home and the home must therefore seek other methods of dealing with this problem. Individual’s rooms were all comfortable. Individuals had chosen the décor and had personalised their own rooms with support from the staff team. The home is appropriately adapted to meet the needs of the current client group. Specialist equipment has been obtained for individual’s following identified need. In order to ensure a well maintained homely environment for the clients it is recommended that attention is paid to the following areas: Ground Floor corridor skirting and doors to be re-painted due to the damage caused by wheelchairs. The water damaged ceiling tile on the ground floor be replaced or re-painted. The small lounge, wall to be given attention/repair, the area including the ceiling to be redecorated. The sluice area on the ground floor to be cleared of excess rubbish. Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 22 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 The relationships between staff and clients are good, creating a warm, supportive environment in which the individual’s quality of life is improved. Robust systems for the recruitment and selection of staff are in place. EVIDENCE: The organisation operates a corporate robust recruitment procedure and the personnel department ensure that all appropriate employment information is collated prior to the start date. A requirement was made at the previous inspection that staff records must be held at the home and be available for inspection, a number of staff records were examined during this inspection and the following information was seen to be in place; application form, a criminal records bureau check, references and a copy of their terms and conditions of employment. The manger has recently reviewed the staffing structure at the home and has consulted with their line manager, an agreement has been reached that the current vacant deputy managers post will not be filled but will be replaced by a senior support worker, the effectiveness of this will be reviewed at the next inspection. Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 23 The inspector saw on records that staff have recently attended the following training; manual handling, food hygiene, first aid and fire safety instruction, positive response training and epilepsy awareness. The inspector was told by the manger of the forthcoming staff meeting; areas of discussion will include person centred planning and valuing people, these meetings take place on a regular basis and provide a forum for staff to air their views, exchange ideas and set future team goals in order to provide a good service for those living at Flaxpits House. The staff present conveyed to the inspector a warm, caring approach to the clients, and demonstrated a good understanding of the individuals communication methods used. Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 24 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 42 The home is well managed ensuring that client’s interests and rights are promoted and protected by a knowledgeable and experienced staff team within a environment that on the whole is a safe one. EVIDENCE: Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 25 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, and has achieved her A1 NVQ Assessors award and also her Registered Managers Award. The manager is currently registered and is in the process of undertaking a National Vocational Qualification in Care Management at level 4. Throughout the inspection it was evident that the manager had a good understanding of the service being provided, individual clients care needs and the legislation in respect of managing a care home. Ms Browne provides a clear sense of direction, and had strategies in place to ensure staff develop the skills and expertise to undertake the tasks they are to perform, staff commented that Ms Browne was approachable, open and listened to staff views and acted where appropriate. It is required that all staff must receive sufficient fire safety instruction in order that those living at the home are supported by competent staff who are working in line with the organisations fire policies and procedures. It was found at the previous inspection that clients inventories had not been updated for some time, one client had purchased expensive sensory equipment for their room yet this had not been recorded. Other clients had no inventories in place; it was recommended that these records be updated in order to reflect correct information on service users possessions. As there has been no attempt to rectify this the recommendation remains and will 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 was identified at 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 the last inspection 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. The home has sought the views of professionals who have supported clients and their views on the whole were very positive and included comments that staff have a genuine interest in the care of each individual and that they were kind and patient. A valid insurance certificate of insurance were up to date and in order. The commission receives copies of the monthly monitoring visits carried out by a representative of the provider. Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 26 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x 3 x 1 Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 3 3 2 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 x Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Flaxpits House Score 3 3 2 2 Standard No 37 38 39 40 41 42 43 Score 3 3 1 3 3 x 2 D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 27 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. Standard YA 9 YA 14 YA 42 YA 6 YA 20 YA 30 YA 24 Regulation 13(4)b 13(4)b 23(4)b 15 13(4)c 13(3) 37 Requirement Individuals risk assessments to be reviewed and updated where required. Holiday risk assessment to contain more detail. All staff to recive sufficent fire instruction. Individuals care plans to be updated and reviewed. A risk assessment must be completed re the use of rectal diazepam. Toilet roll, soap and hand towels to be available for individuals use. The Commission for Social Care Inspection to be kept informed of the proposed buiding works, a variation application must be completed. It is required that an effective Quality Assurance monitoring system based on seeking the views of clients is developed. It is required that each individual has a copy of the terms & conditions between the home and the client. It is required that staff who administer medication must undertake competency training Timescale for action 29/08/05 29/08/05 29/08/05 29/07/05 29/07/05 29/06/05 29/07/05 8. YA 39 24 29/08/05 9. YA 5 4&5 29/08/05 10. YA 20 29/010/05 Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 28 by an accredited trainer. 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. Refer to Standard YA 11 YA 40 YA 41 YA 21 Good Practice Recommendations Clients action plans should contain photograpghs or pictures in order to enable individuals to make choices. Organisational policies and proceedure headings to be updated to reflect the status of the current organisation. Indivdiduals 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. Flaxpits House D56 D05 S3383 Flaxpits House V228771 290605 Stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection 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
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