CARE HOME ADULTS 18-65
Flaxpits House 74 Flaxpits Lane Winterbourne South Glos BS36 1LB Lead Inspector
Odette Coveney Key Unannounced Inspection 31st July 2007 08:30 Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 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 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (10), Physical disability (10), of places Physical disability over 65 years of age (10) Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Male and Female 35-64 years and 65 years and over Date of last inspection 22nd March 2007 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 newly planted plants 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. More recently there has been a further extension to the property. This includes a one-bedded bungalow and an additional two bedrooms and one bathroom. 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 ten adults with learning and physical disabilities. The registered manger is Dionne Browne, who has been in post since June 2003. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. This inspection employed key elements of the national inspection methodology with the objectives of focusing on outcomes for the individual’s. This is evidenced through evaluation of core standards and verification through a surveying and case tracking approach that included talking with and the observation of individuals who live at the home and the views of the registered manager and the staff on duty. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for three of the individuals were reviewed. A good number of comment cards were received prior to the site visit, all contained many favourable comments about the service provided to individuals who live at Flaxpits House. Five were from residents, one was from a relative of an individual who lives at the home, and two were from health/social care professionals who have supported individuals at the home. Comments made were reviewed during the site visit and comments, maintaining individuals confidentiality were shared with the manager and these have been incorporated within this inspection report. What the service does well:
There are individuals living at Flaxpits House who have complex needs, including specialist communication, emotional and physical support needs. The environment at Flaxpits House is well suited for the needs of individuals living at the home; one service user benefits from a self contained, purpose built flat and is supported by staff on a one to one basis. Staff are recruited and selected appropriately ensuring that individuals are protected by robust practices, staff are well trained with sufficient numbers of staff on duty to support the identified needs of service users. Individuals have access to a range of social and leisure activities based on individual’s choices and likes, these are well recorded. The home have developed a good quality assurance process based on seeking the views of individuals living at the home, this combined with the systems in place by the Trust are sound methods to ensure those living at Flaxpits House are well supported and leading fulfilling lives.
Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection?
The manager and staff at the home have worked diligently since the last site which was undertaken on 22nd March 2007 and the Inspector was satisfied that all 12 requirements and the 6 recommendations had been met and information in respect of these are detailed below. The home have ensured that those living at the home are supported safely and that staff are working in line with manual handling regulations as the home have ensured that manual handling assessments for service users have been completed. Individuals living at the home appear to be treated with respect and no concerns in respect of staff manner or approach were observed during this site visit. In order that individuals can be assured that their money and property are clearly accounted for the home have ensured that individuals monies held for safekeeping correspond with records held, also inventories of personal property are in place and these are updated when required. In order that individuals can have access to equipment which has been provided for them the home have ensured that the track ceiling hoist was repaired for an individuals use in accordance with their assessed need. Service users are better supported and feel can confident in staff skills, as staff have been provided with positive response training. Also as all staff have undertaken protection of vulnerable adults training, and also as staff have received sufficient amounts of training in order to fulfil their role and records of staff training have been better maintained. In order to demonstrate that individuals have been supported appropriately and that the home is working in accordance with the Care Homes Regulations 2001 the manager has ensured that the Commission has been notified of incidents, which have affected the well-being of those living at the home. In order to fully demonstrate that individuals have been consulted, that their views had been sought and listened to and where needed acted upon the home have developed a quality assurance monitoring system based on seeking the views of service users. In order to ensure that individuals are safe, evidence has been seen and provided at this site visit to show that all staff at the home that administer medication have undertaken appropriate training to demonstrate their competency. Also stock medication tallied with records held. Individual’s action plans contain photographs or pictures this enables individuals to make choices.
Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 7 From discussion with the manager and staff and observations of interactions between staff it was evident that morale within the home had improved. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need about Flaxpits House, however the statement of purpose would be improved if the photographs within this document were updated. Individual’s aspirations and needs are well assessed and recorded. Improvements must be made to ensure that all individuals have clear contractual arrangements in place. EVIDENCE: The statement of purpose in place at the home was detailed and fully outlined the rights of service users and recorded the responsibilities of the management and staff employed at the home in order that the aims of the home are met. Information contained within the statement of purpose includes the staffing arrangements. There is also information about the admissions process and whom the home are able to care for. Information within this document outlines how each person’s needs, both from a holistic and individual perspective will be met, recorded and reviewed and updated when needed. There are a number of photographs incorporated within this document; it is recommended that photographs within this document be updated in line with the changes that have occurred in the home to show the improvements made to the environment. Admission to the home is through the care management approach and each admission is on a planned basis. There are presently no vacancies at the home.
Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 10 Aspects and Milestones Trust have a clear criteria about what needs are and are not able to be met at the home and also take into consideration the needs and views of those already living at the home before any decision is reached. Records seen confirmed that individuals are admitted to the home for a trial period in order that a fuller picture of the services provided can be made and also in order for the home to undertake further assessment of need, this trial period would be extended if required. Evidence of this was also seen at this site visit. The inspector saw that the home had ‘licence agreements’ in place, which provided information about the home’s complaints procedures, fire safety, visitors and fees. It was noted that not all of these documents had been fully completed and not all service users/and or their representatives have been given a copy of this document. The Registered Manager/Provider must ensure that all service users must be provided with this contract outlining the terms and conditions of their placement. This is to ensure that services users are aware of their rights and also that the rights and responsibilities of the service provider are outlined within a standard form of contract which provide information in respect of the accommodation to be provided, including the amount and method of payment of fees. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 8, 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Services users can be confident that their individual assessed and changing needs are well record, reviewed and met. Individuals are supported to make decisions and are consulted. Individuals are supported to take risks however a risk assessment must be completed on the use of a piece of equipment. EVIDENCE: The manager and staff spoken with were able to give detailed information about the physical support, care, and emotional and healthcare needs of those living at the home. Miss Browne and staff spoken with were fully conversant with individual’s changing needs and areas of their life, which are important to them and how the home can ensure that these needs are met. The care plans and associated documents for three service users were fully examined during this site visit, the documentation for three others were also sampled. Information contained within individuals files included, personal information, daily support needs and essential lifestyle documents, risk assessments, information about how individuals are supported to participate in
Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 12 social and leisure activities. Individuals support needs included detailed information in respect of how they wish to be supported in areas such as their communication, mealtimes, being safe in the house and personal support. Following a review of individual’s daily records it was noted that there was some use of inappropriate language in respect of how some staff described individuals behaviour. Therefore it is recommended that consideration should also be given to the use of language within these records. In order to demonstrate that staff have an understanding of individual’s needs and behaviours and also to ensure that individuals are being treated with dignity and respect. A requirement which had been outstanding since January 12th 2006 was that manual handling assessments must be completed, a management review meeting was held with the registered manager and a representative of the responsible individual after the last site visit, during this meeting a review of these documents found that the home had completed full and detailed assessments in this area, risk assessments seen included; using a stand aid, use of bed rails and use of a high/low bath. In order that service users can be assured that staff are provided with sufficient and appropriate information it required that a risk assessment is completed in respect of the use of a ceiling track hoist. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are supported to take part in age, peer, and community activities and are assisted to maintain relationships. EVIDENCE: Staff when talking about individuals used services users preferred form of address as recorded in care plan documentation. During the site visit staff were observed interacting with service users and not talking exclusively to each other. It was recommended at the last key site visit to the home that individual’s action plans should contain photographs or pictures in order to enable individuals to make choices. The inspector spent time with a recently appointed staff member who spoke with enthusiasm about the progress made in this area showing information they had gathered and plans to develop this process, this will be reviewed at the next site visit.
Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 14 Information within individuals monthly review meetings and information seen in care plans and daily records show that all individuals at the home have been supported to participate in a variety of social, educational and leisure activities based on their abilities and choices recorded in notes was evidence that individuals receive one to one support to attend college, go shopping, swimming, holiday, hydrotherapy, attending day services, visiting the pub and meals out. The kitchen was seen to be well stocked with fresh fruit and vegetables, many of the meals at the home are ‘home made’, during this visit the inspector saw that individuals likes and dislikes were well recorded and at lunchtime all individuals had a different meal based on their preferences. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals receive the support they prefer with individuals physical and emotional needs being well met. Systems of medication administration, recording and storage are well managed. EVIDENCE: Information seen in care records, interactions observed between staff and service users, information recorded in daily diaries and risk assessments showed that guidance and support regarding personal hygiene is given when required and at a level and pace appropriate to the service users. All service users are registered with a local GP and information seen in records confirmed that individuals are supported in other specialist areas of their heath such as complex emotional behaviours and epilepsy. From discussions with the manager and information seen in care records it was evident that people at the home are supported to attend health appointments and records are completed after each visit. This ensures a consistent approach to meeting individual needs. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 16 A requirement made at a previous site visit was that evidence to be forwarded to demonstrate that staff that administer medication have undertaken competency training by an accredited trainer. This had been forwarded and during this visit it was found that staff would be completing an in depth training session the following day with the pharmacist who supplies medication to the home. There were three recommendations were made at the last key site visit these were as follows: that printed medication administration sheets must correspond with medication given, written advice/confirmation to be obtained from the prescribing general practitioner in respect of the use of crushed/covert medication administration and also that medication profiles to be updated. A full review of medication administration and systems during this visit found that all of the recommendations had been met and no concerns or errors were found. Healthcare plans were in place for all individuals, these were comprehensive and outlined key workers responsibilities in specific areas such as record keeping and review of health needs and appointments, these plans evidenced that individuals are supported well in aspects of both their physical and emotional care. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are supported to raise issues of concern and the Trust has robust systems in place in order to protect individuals from abuse, neglect and self harm. EVIDENCE: The Home has appropriate procedures in place for management of complaints. The home has a complaints policy and procedure this document contains information about the Commission for Social Care Inspection to enable individuals to contact the Commission if they were not satisfied with the outcome of their complaint to the home. There is a copy of the South Gloucestershire Council policy on The Protection of Vulnerable Adults from Abuse at the Home to ensure that the Home is aware of the protocol to be followed if incidences of abuse occur. Records of recently employed staff members were viewed and contained personal information and record of identity. Other information seen included two satisfactory references, record of previous employment, and satisfactory Criminal Record Bureau disclosures. Three requirements were made at the last key site visit to the home in March 2007 these were that The Commission must be notified of incidents that have affected the wellbeing of those who live at the home. This has been met, incidents have been well reported. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 18 Another requirement made at the last key site visit to the home was that Protection of vulnerable adults training must be provided for all staff, this has been provided and all staff have received training in this area. The third requirement made was that service users money must be clearly accounted for. A review of the money held for safekeeping for three service users found no errors and both incoming and outgoing monies were correctly recorded. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals live in a home that is safe and the quality of furnishings are of a high standard and suitable for the needs of residents EVIDENCE: Flaxpits House is a spacious residential Home and is furnished to a high standard. The house is a detached property and is situated in Winterbourne and is close to private houses and a short distance from local shops and is nearby to bus stops. This helps ensure individuals can be a part of the community. The Home is wheelchair accessible; however there is no lift servicing the first floor and individuals who have rooms in this area of the house have to be fairly ambulant. There are adaptations in place throughout the home and specialist equipment including manual handling aids, and specially adapted baths, a requirement was made at the last key site visit to the home was that ceiling hoist must be repaired. This had been and was in working order at this visit. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 20 There is a spacious dining area and two comfortable lounge areas with views onto the rear garden. Individuals were observed sitting in the lounge, the garden and going into their rooms, looking reasonably relaxed and comfortable in their environment. The garden to the rear of the home is kept safe, tidy and accessible to service users and there is seating available to individuals when the weather is good, there is a small summerhouse in this area and a small vegetable plot where service users have been supported by staff to grow A brief tour of the building found the home to be comfortable and had an array of soft furnishing which made the home very homely. Bathrooms include specially adapted baths to assist individuals who may have reduced mobility. Toilets are situated in readily accessible parts of the Home near to communal areas and bedrooms. The bathrooms and toilets were clean, and were well stocked with hand towels and soap to help minimize risk from cross infection in the Home. It was evident from interactions between staff and individuals during the inspection that staff have developed positive relationships with individuals. The home employs a domestic to assist with the cleaning of the home; this person was seen to be completing their duties during the site visit and the home was found to be clean, tidy and odour free in those areas viewed by the inspector. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33, 34, 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had sufficient staff on duty and staff are qualified to provide good level of care. Service users have confidence in the staff that care for them. All staff are clear regarding their role in what is expected of them. Recruitment practices safeguard individuals. EVIDENCE: On the day of this site visit, there was a friendly and interactive atmosphere in the home. Individual’s looked well cared for and were noted to appear relaxed and ‘at ease’ in their home. 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. Recruitment and selection records were looked at and showed that the necessary checks are place i.e. 2 references and Criminal Records Bureau
Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 22 Check (CRB). Application forms provided full and detailed information about applicants including full employment history, as required. Requirements were made at the last key site visit to the home which were that staff must receive sufficient amounts of training in order to fulfil their role. Training records were looked at and evidenced that those inspected had undertaken the mandatory areas of training; such as manual handling, first aid fire safety and National Vocational Qualification. Staff spoken with said they felt well supported with their training needs. It was further noted that experts had provided training for staff in order to support individuals with complex behaviours in order to find solutions to meet individual’s needs. Positive response training has been provided for staff in order that they have the knowledge and skills to deal with potentially difficult situations. It was recommended at the last key site visit that staff training records should be updated. These were reviewed at this visit and were found to be up to date with training undertaken well recorded. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The practices within the home have offered protection to the health and safety of residents. The home is run in the best interests of the service users. The home is well managed ensuring that individual’s interests and rights are promoted and protected by a knowledgeable and committed staff team. EVIDENCE: The Registered manager Dionne Browne has over three years management experience within this care setting and has extensive experience of working with adults who have learning disabilities. Miss Browne was present during this site visit. Dionne Browne and the staff team were positive and motivated throughout the inspection process. There was evidence that the manager and her team were committed to maintaining good levels service provided at Flaxpits House and also to improving services.
Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 24 Regular staff meetings are held at the home, staff said these were a useful forum in order to ensure effective communication and continuity of service for individuals living at the home. Meetings are also held monthly with the senior staff at the home, some notes for these were seen, however they had not been formalised. Therefore it was recommended that senior management meetings are written up and are available for reference. There was evidence that the home ensures so far as is reasonably practicable. the health and safety of service users staff and visitors. The home has robust policies and procedures in relation to aspect of health and safety. Accidents were recorded appropriately and reviewed as required. The fire log-book was noted to be up to date and evidence from records and confirmation from staff showed that staff have attended fire drills. The home has a fire risk assessment in place. There are clear equal opportunities policies within the home and these are available to staff. Staff meetings are held regularly and there are also other strategies for enabling staff, service users and other stakeholders to voice concerns and to affect the way in which service is delivered. These included staff supervision, service users monthly review meetings, internal formal, structured quality assurance, and therefore the requirement made at previous site visits that the home must develop an effective Quality Assurance monitoring system based on seeking the views of service users had been met. It was recommended at the last key site visit that Individual’s inventories must be updated. This had been completed. This visit did not focus on the financial viability of the home. There was no evidence that the financial viability of the service was threatened in any way. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 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 3 25 X 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 26 No 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. Standard YA5 Regulation 5(1) b Requirement Timescale for action 31/07/07 2. YA9 13(4) c Licence agreements must be in place for all service users and must contain full and detailed information. A risk assessment must be 31/07/07 developed for the use of a ceiling hoist. 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. Refer to Standard YA36 YA6 YA1 Good Practice Recommendations Senior management meetings must be recorded Consideration must be given to the use of language and terminology in service users daily diaries. The photographs accompanying the homes statement of purpose must be updated. Flaxpits House DS0000003383.V340736.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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