Inspection on 06/10/05 for Follybridge House

This inspection was carried out on 6th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Follybridge House 18/04/08

Follybridge House 18/04/07

Follybridge House 24/11/06

Follybridge House 07/02/06

Follybridge House 28/02/05

Follybridge House 29/06/04

Follybridge House 24/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Follybridge House Bulbourne Road Tring Herts HP23 5UG Lead Inspector Sue Smith Unannounced 6th October 2005 at 11.15am 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. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Follybridge House Address Bulbourne Road, Tring, Herts, HP23 5UG 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) 01442 828285 Turning Point Limited Alan Wilson Care Home 6 Category(ies) of Learning Disability (6) registration, with number of places Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28/02/05 Brief Description of the Service: Follybridge House is situated in a quiet rural area, backing on to a nature reserve accessible to Service Users. The home has large, attractive and wellmaintained grounds, which contain a sensory garden, a trampoline, and swings. The home is part of the charitable organisation Turning Point, which provides residential accommodation for people with learning disabilities and mental health problems. Follybridge House accommodates up to six male Service Users with behavioural problems and learning and communication difficulties. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by Sue Smith and Barbara Mulligan on the 6th October 2005 over 2.5 hours. The Manager was available throughout the Inspection. During the inspection 30 of the National Minimum Standards for Younger Adults were assessed with 28 fully met and 2 partially met. The Home has received 2 requirements and 2 recommendations to support practice. During the inspection the Inspectors sampled a variety of documents, which included, Careplans, Training, Supervision, Recruitment, Health & Safety and the Statement of Purpose and Service Uses Guide. A full environmental tour was undertaken with the support of the Manager and 1 Service User. Staff interaction with Service Users was observed throughout the inspection. The Inspector would like to thank the Service Users, Manager and his Team for the warm welcome they received and support given to complete the inspection. What the service does well: The Home provides a holistic approach to care, which is undertaken in a sensitive and professional manner. Staff provide support for Service Users to access the wider community and undertake activities that are both enjoyable and educational. The Service is well managed by an approachable, open and transparent Manager. Staff receive training, which supports them in their roles. Staff practice at the Home was reflective of a knowledgeable and skilled team. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 6 Recruitment procedures are rigorous with all necessary security checks in place to ensure the protection of Service Users. Risk assessments are in place that both protect the Service User from harm and ensure they are able to maintain and develop their independence. Families are welcomed to the home with Service Users supported to maintain their links with families and friends. Meals provided are nutritious, varied and appealing with menu planning taking into consideration the specialist dietary needs of Service Users. A programme of redecoration and refurbishment is in place with communal areas of the home recently decorated. The Home is well maintained with no outstanding health and safety issues. The Home provides large communal areas, sensory areas and single accommodation bedrooms that have all been accessorised and decorated to the personal preferences of Service Users. Medication procedures in the home are maintained to a high standard. There is a comprehensive complaints procedure with no complaints received at the home or directly to the Commission in the past 12 months. The Organisation provides policies and procedures, which ensure the safe operation of the Home within current legislation and guidance. What has improved since the last inspection? The exterior of the House has now been painted. The communal lounge and dining areas have now been decorated. New washing and drying facilities have been purchased and will be fitted as soon as is reasonably practicable. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 7 The Home continues to provide a high standard of care implemented in a sensitive and supportive manner by a suitably trained and skilled staff team. 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. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 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 standard(s) 1, 5. The Home has a Statement of Purpose and Service Users Guide, available in a variety of formats to support Service Users, however these require further work to ensure they meets all points of Standard 1 and Schedule 1, thus providing the necessary information for Service Users prior to admission. All Service Users have a contract of their terms and conditions; this is explained at an appropriate level of understanding to protect the rights of Service Users. EVIDENCE: The Home does have a combined Statement of Purpose and a Service Users guide, which is available in a variety of formats, however on reading this document there are important areas of schedule 1 missing. The inspectors have advised the Manager that the document in its present form is more in line with the requirements of a Service User Guide and have suggested parts of the document be pulled out following the guidance of standard 1.2, thus providing a document in a language understood by Service Users which could then be named The Service Users Guide. The Home will then be required to formulate a full Statement of Purpose following the eighteen points set out in Schedule 1 of the Care Standards Act 2000. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 10 Contracts of terms and conditions are held for each Service User, these are held in the individual files and are reflective of the fees charged. Either the Service User or a representative has signed all terms and conditions. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 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 standard(s) 6, , 8. The Home provides Person Centred Plans; these require further work to ensure staff are able to provide appropriate documented support to the individual Service User. Individual risk assessments are in place, which support the Service User to live their lives as independently as possible. EVIDENCE: The staff team have been working towards producing Careplans that are formulated following the principles of Person Centred Planning. Work has taken place to ensure a full history of each Service User is obtained. At this point the Home has a vast amount of information that will support staff to develop mutually agreed objectives and goals which will support the Service User to fulfil their dreams and aspirations. The Home are reminded when formulating these plans that they will need to ensure specific health care issues are documented with records of relevant monitoring. The Home will need to develop these plans as soon as is reasonably practicable as at this time there is no evidence of what and how care is implemented. The Inspectors have not Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 12 issued a requirement as the Manager is working towards the completion of these plans. Risk assessments are in place to ensure any potential risks to the Service Users are minimised whilst maintaining their independence. These were reflective of review and were relevant to the current needs of Service Users. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 16, 17. Service Users are supported to access a wide range of activities, which meet their social, spiritual and leisure needs. Service Users are supported to access the local community, which as has aided them to become part of the community. Staff support Service Users to maintain links with their family and friends Meals offered at Follybridge House are wholesome, varied and appealing to ensure the nutritional needs of Service Users is met. EVIDENCE: Service Users are supported by Staff to access a variety of activities both as a group and 1:1. Vehicles are supplied at the Home to aid Service Uses to access the wider community. All Service Users attend day care services with 1 accessing The Sunnyside Project, 4 accessing Jarmans and 1 accessing The Orchards. Evening activities consist of visits to local shops, pubs, restaurants, Gateway Club, visiting local amenities and family outings. In addition to Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 14 activities in the wider community the home also has a large sensory garden, a sensory room for relaxation and such things as foot massage. The Home has recently erected a greenhouse, which will be used for planting activities. Each Service User has a day in the home when they are included in the day-to-day cleaning of the home and are supported to maintain their own bedrooms. Families and friends are welcomed to the home with no restrictions in place. The Service Users at Follybridge have maintained their relationships with families with staff supporting them with such things as transport to parents homes for weekend visits and providing details of coming events. During the inspection Service Users and staff were seen to observe the rules of the house for example no smoking inside. There was positive engagement between staff and Service Users with Staff exhibiting an understanding of Service Users individual needs, the atmosphere within the home was relaxed and jovial. Special attention is given to the formulation of menus at the home due to the health care needs of Service Users. Two separate menus are in place to support Service Users with specific dietary needs such as PKU meals, with additional meals that can be adapted for all Service Users to enjoy included. The menus are flexible, for instance on days where mince is recorded it is entirely up to the Service Users and Staff to decide how this will be used, e.g. lasagne, spaghetti Bolognaise, meatballs etc. In the kitchen a preference list is available on the notice board to further support this system. Meals are eaten in a comfortable and spacious dining area. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 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 standard(s) 18, 19, 20, 21. Personal care is delivered in a professional manner that ensures the individual likes and dislikes of Service Users is acknowledged. Service Users physical and emotional care needs are met through the person centred planning approach adopted by the Home; this ensures a holistic approach to care delivery. Medication procedures in the Home are robust and ensure Service Users are protected. The ageing, illness and death of a Service User will be treated with respect, ensuring consideration for the Service User and family wishes. EVIDENCE: All personal care is delivered in a sensitive and professional manner taking into consideration the preferences of the Service User. Staff were observed supporting Service Users throughout the inspection, practice was reflective of a knowledgeable staff team who are patient and understanding of the limitations and specific needs of Service Users. All care is implemented in a manner that enables the Service User to maintain their independence and build on their existing skills. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 16 As previously mentioned in this report the Home is adopting the Person Centred Planning approach to care delivery. This method of care delivery is still in its infancy with additional work required to bring the Careplans in line with current legislation. The Care Team have embraced the philosophies of Person Centred Planning and are delivering a care package that is both holistic and Service User centred. The Care implemented at Follybridge House continues to be delivered to a high standard and is to be commended. The Home has robust medication procedures in place to ensure the safety of Service Users. Suitably trained staff administers all medication with MAR (medication administration records) found to be appropriately signed. There were two gaps evident for the application of creams; the Manager needs to remind staff to ensure these applications are recorded appropriately. Controlled medicines have been used recently in the home; there is a controlled drugs book, which was found to be appropriately signed by two members of staff on all occasions. All controlled medication is appropriately stored in a lockable facility. The Manager usually completes returns (or Deputy Manager) with signatures in place; the Pharmacy will then collect all returns from the Home. The Inspectors have advised the Manager to obtain a signature from the collecting person to complete the audit trail. In addition to the prescribed medication used in the Home a homely remedies book is also in place with all administrations recorded. The Home also holds such things as TCP, plasters, paracetamol, euroax lotion and other creams for staff usage, these are stored in a tub separate from Service User medication with administration records in place. The Manager has formulated an in-house medication protocol, which gives clear guidance of how medication is to be administered, the Manager was advised to ensure he dates and signs this document. In addition the home has a copy of the Hertfordshire Community Living Services Policy, to further support practice, however this policy is dated April 1996. The home is required to provide a more up-to-date medication policy, which is reflective of review. The Home has discussed with families their wishes in the event of death. This is a difficult subject to approach, which has been undertaken with sensitivity and consideration to the wishes and needs of both Service Users and their families. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 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 standard(s) 22 The Home follows a thorough complaints procedure to ensure an open, and transparent practice is in place, which protects the Service Users. EVIDENCE: There have been no complaints received at the Home or directly to the Commission in the past 12 months. The home operates an open door philosophy where issues of concern can be raised to minimise the need for formal complaint. All complaints are documented and investigated in line with current policy guidance and are actioned within the recognised timescales. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 18 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. Follybridge House is a homely and pleasant environment, which is undergoing refurbishment to ensure the needs of the Service Users, is met. The Home is well maintained ensuring Service Users live in a Home that is clean and hygienic and maintains the health and safety of Service Users and Staff. There are sufficient numbers of communal toilets and bathroom with adaptations and equipment in place to ensure the needs of Service Users is met. Suitable single room accommodation is provided with adaptations and equipment in place to ensure the needs of Service Users is met. EVIDENCE: There is an evident programme of decoration and refurbishment in place with the exterior of the House recently painted and the communal lounge and dining areas recently decorated. The Manager and his team have been exploring how they can better use space in communal areas and will be Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 19 implementing some of their ideas once the redecoration has been completed. The Lounge and dining area are large and equipped to meet the needs of Service Users. In addition to these areas the Home have used a small room attached to the lounge as a sensory area, this has been fitted with equipment and comfy furnishings to enable this area to be both functional and therapeutic. The Home is well maintained with no outstanding health and safety issues to report. Staff ensure the home is cleaned to a high standard, with infection control measures in place. The Home was found to be clean, tidy and free from offensive odours at the time of inspection. Service Users do participate as much as they are able in the day-to-day cleaning of the home with support from the Staff team. All items of C.O.S.H.H. are stored in lockable facilities to further ensure the safety of Service Users. The Home is awaiting the delivery of a new Washer and Dryer to further improve the facilities offered. Those presently used include a sluicing facility, are maintained to a high standard with replacement taking place due to their age. Once the more intricate electrical details have been finalised the new equipment will be operational. There are sufficient numbers of communal toilets and bathrooms situated within close proximity of bedrooms and communal areas. These are brightly decorated and are warm and inviting. All Service Users have single accommodation bedrooms that have been adapted to meet their individual needs. These have been decorated to reflect the personalities and preferences of Service Users. The Inspector commends the team for the time and effort taken to ensure these are not only comfy and homely but are enjoyable and relaxing environments, the inspector would like to compliment the intricate and inspiring murals, sensory aids and additional fixtures and fittings that are evident throughout the bedrooms. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 20 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, 34, 35, 36. The Home has a skilled staff team who ensure the Service Users needs are met in a safe and professional manner. Staff are supported to carry out their roles through a supervision and training programme, which enables staff to discuss issues of practice in an open and transparent manner. The Home has a full recruitment procedure in place, which is in line with Schedule 2 and Standard 29, to protect the intrinsic rights of Service Users. EVIDENCE: Staff receive training, which supports them in their roles. All mandatory training is taking place in line with current legislation. A full assessment of this standard will take place at the next inspection to ensure all up-dates of mandatory training have taken place. Staff practice was observed throughout the inspection, which was reflective of a knowledgeable and skilled team. Staff receive regular supervisions between four and six weeks to ensure they are able to discuss practice issues and the changing needs of Service Users in a structured and confidential forum. Records of supervisions are held in individual personnel files, all supervisions were found to be up-to-date. In addition to regular supervisions the home also undertakes an annual appraisal. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 21 Recruitment files were assessed during this inspection, all files are held in lockable facilities. The Home have recently changed the way in which they recruit staff by initially offering bank posts to ensure staff are suitable for the Home and the Home is suitable for staff. This has been a positive initiative which has ensured a high calibre of staff have been offered full time employment should they wish. The procedures for recruitment are robust with copies of all documentation held in the home which includes, application forms, interview notes, confirmation of start date letters, two written references, photo identity, previous training certificates, contract of terms and conditions and a confirmation memo from the HR department for the receipt of CRB disclosures. It was noted by the Inspector the confirmation memo does not include the CRB number or if a check has been made against the POVA list with satisfactory results, the inspector has recommended these points be included to further improve the practice of the Organisation. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 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 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) 38, 39, 41, 42, The Management approach to the Home is open and transparent, ensuring the needs of Service Users are met in a safe and professional manner. Service User views and opinions on the day-to-day operation of the Home are sought through a variety of systems to ensure the Home is operating in the best interest of the Service User group. The Organisation provides policies and procedures, which enable the staff to provide a professional service. The Home follows current Health and safety legislation and guidance to ensure the Service Users at Follybridge House are protected from harm. EVIDENCE: The Manager is open and transparent in his practice. Throughout the inspection the Inspectors observed a calm and relaxed approach to the management of the home, staff appeared comfortable with the manager who Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 23 made himself available when staff required his attention. The Manager is very much part of the team ensuring he is included in the day-to-day support of Service Users as well as putting time aside to attend to the management aspects of the role. The Manager and his Team are to be commended for the relaxed, supportive and homely environment they have created whilst maintaining the safety of Service Users. Service User participation in all aspects of the day-to-day operation of the home is supported by a proactive and knowledgeable team who are consistently reviewing the way care is implemented. Policies and procedures are in place, which support the Manager and his team to provide a professional service that is in line with current legislation. As previously mentioned the medication policy does need to be up-dated to ensure it is in line with current pharmaceutical guidance. The Inspectors assessed a variety of health and safety documents to ensure the home is operating within current guidance. These are as follows: A legionella test certificate was obtained on the 20/05/04. PAT testing last took place 21/5/04. A hard wiring test certificate was received January 2003; Boiler testing is due December 2005. In addition monthly health and safety monitoring takes place which includes temperature readings of hot water outlets and a general health and safety check to identify hazards. Generic Risk Assessments are in place for both the internal and external areas of the Home, which includes equipment. The home operates rigorous fire procedures with weekly checks of fire points, monthly checks of emergency lighting and weekly fire alarm checks. In addition service records were open to inspection of all fire equipment held in the home. The home has clear policies on First Aid, RIDDOR and a comprehensive health and safety policy which describes the organisational arrangements and corporate procedures which includes the reporting of accidents, COSHH, infection control measures and moving and handling. There were no requirements for improvements under Health and Safety. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 24 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 2 x x x 3 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score 3 x x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Follybridge House Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x 3 3 x 3 3 x 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 25 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 1 Regulation Schedule 1. 13 (2) Requirement The Statement of Purpose and Service Users guide be updated to reflect all areas of schedule 1 and standard 1.2. The Homes Medication policy be up-dated to reflect current guidelines. Timescale for action 06/01/06 2. 20 06/01/06 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. Refer to Standard 6 34 Good Practice Recommendations Future planned work to the PCP files to provide mutually agreed careplans and goals be implemented as soon as is reasonably practicable. The memo confirming CRB disclosures be reviewed to reflect the CRB number and that a POVA check has been undertaken with no evident entry to the POVA list. Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 26 Commission for Social Care Inspection Cambridge House 8 Bell Business Park Smeaton Close Aylesbury, Bucks. HP19 8JR 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 Follybridge House 20051409 Follybridge X100023 UI Stage 5 S22972 V237867 H53.doc Version 1.40 Page 27 - 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. 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