Inspection on 19/10/07 for Forge House

This inspection was carried out on 19th October 2007.

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

Forge House 06/03/07

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Forge House Forge House 60 Higher Street Cullompton Devon EX15 1AJ Lead Inspector Sue Dewis Unannounced Inspection 19 October 2007 10:00 Forge House DS0000067786.V350127.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 Forge House DS0000067786.V350127.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. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Forge House Address Forge House 60 Higher Street Cullompton Devon EX15 1AJ 01884 32818 01884 38777 forgehouse@ukhcg.com 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) FORGE HOUSE SERVICES LIMITED Anna Jane Leinster Care Home 11 Category(ies) of Learning disability (11), Physical disability (11) registration, with number of places Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 2007 Brief Description of the Service: Forge House is a large detached property in the town of Cullompton. The house is spacious and homely. Some adaptations on the ground floor have been made to meet the needs of physically disabled people. There are eleven single bedrooms with wash-hand basins in each. The home has a large lounge and dining room, kitchen, a smaller lounge, an office and a number of communal bathrooms and toilets. There are gardens to the front and rear of the property. Fees range from £681.91 to £928.73 per week. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at http:/www.oft.gov.uk . The most recent Commission inspection report is available upon request from the home’s office. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 8 hours, one day in the middle of October 2007. The home had been notified that an inspection would take place within three months and had returned a completed AQAA (Annual Quality Assurance Assessment), information from which was used to write this report. During the inspection 3 people were case tracked. This involves looking at peoples’ individual plans of care, and speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. As part of the inspection process we like to ask as many people as possible for their opinion on how the home is run. On the day of the visit we left questionnaires for all 8 people living at the home and 10 staff. At the time of writing the report, responses had been received from no people living at the home and one member of staff. Their comments and views have been included in this report and helped us to make a judgement about the service provided. Some people living at the home have limited verbal communication skills. We are not skilled in their other methods of communication and so it was difficult for us to have any meaningful communication with them. However, the interaction between the people living at the home and those who care for them was closely observed. During the inspection one person living at the home was spoken with individually as well as one representative. We also spoke with 2 staff, the home manager and the operations manager for UKHCG (UK Health Care Group) which is the company that owns the service. A full tour of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files. What the service does well: Forge House is a warm and friendly home that provides people living there with individualised and personalised care. There is a good assessment procedure in place for when admissions to the home start again. Staff are well trained and everyone has a care plan that ensures staff have the information they need to meet the needs of the people living at the home. People’s choice Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 6 is sought whenever possible and they are encouraged to be as independent as their abilities allow. Staff demonstrated a good knowledge of the needs of the people they care for and everyone benefits from the positive relationships that have been formed. Medication is stored and administered appropriately. Complaints are dealt with in a positive way and people are kept safe by staff who know their duty to report poor practice and the good recruitment practices in place Representatives are involved in the care of their relative and people are supported to maintain as much contact as they wish. Good food is provided that people help choose, shop for and prepare. There is a good range of activities and outings on offer for people to enjoy, and there is transport to ensure people can get out and about. One person has been supported to obtain their own mobility transport. The environment is safe for people who live there and the owners continue to improve the fabric of the building. The manager of the home, Annie Leinster is appropriately qualified and has many years experience of working with people with learning difficulties. She has good systems in place to ensure the quality of care at the home is maintained. What has improved since the last inspection? What they could do better: No requirements were made following the visit but we made two good practice recommendations. These were that there should be more evidence on people’s daily notes to show what activities they participated in and how much they had/had not enjoyed it. Also, the home should be maintained and decorated in such a way as to ensure people at the home have a comfortable place in which to live. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 7 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. Forge House DS0000067786.V350127.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 Forge House DS0000067786.V350127.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): 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good assessment and admission process in place, which means that people thinking of moving into the home can sure that their needs will be met. EVIDENCE: There have been no new admissions to the home since the current owners took over the management. This was because they were concerned over the condition of the fabric of the building. Recently the home has begun to take referrals for when they begin to take admissions. Following an initial contact from a full assessment has been completed, from this the needs of the person can be identified and their fee calculated. The manager would usually visit the individual to complete this assessment. There is the opportunity for individuals to visit the home prior to their admission if they wish to. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 10 The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to access independent advocates to support individuals where this is required. Forge House DS0000067786.V350127.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, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear care planning system in place, that provides the information that staff need in order to satisfactorily meet the day to day needs of individuals. This would be further enhanced if there was more evidence provided showing how people had participated in activities. Peoples’ choice is sought and acted upon whenever possible. EVIDENCE: Three people’s care files were looked at and all were found to be very comprehensive. They each contained a detailed needs assessment, information on ‘All about me’, risk assessments, planned support, daily information sheets and communications records. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 12 Areas of assessment included independent functioning, stereotyped and hyperactive behaviour and social engagement. There is a summary of the person’s needs that tells staff ‘All You Need to Know’ and includes details of friends and family as well as likes and dislikes. Risk assessments are completed whenever a risk has been identified, including in the community, the kitchen, bathing, eating/choking and they also include any risk reducing activities that need to be put into place. Details of the planned support that is required to meet needs is set out in a clear way which shows short and long term goals and the staff action that is required to meet the goals. Information on the daily routine of individual shows clearly what the individual can or can’t do and exactly what staff need to do to support them. Daily information sheets for each individual give some detail as to what the person had done during the day. The information is now recorded on individual sheets and are maintained in line with the data protection Act. However, the information was limited and did not evidence that staff had done what was needed for each individual in line with the ‘Planned Support’ details. There was evidence on the files that the care plans are reviewed regularly and staff sign each month to say that they are aware of the current care plan for everybody. The care plans also contain the daily routines of the person and any accidents or incidents as well as their wishes relating to dying and death. An ‘in-house’ advocacy group is held regularly and everybody has a chance to say how they are feeling and if they have any concerns, as well as general house matters being discussed. People are expected to contribute to the general running of their home, as far as their abilities allow and are consulted on all aspects. Meals are decided on a daily basis and people help to shop for and cook the meals. Everyone is responsible for keeping their own rooms tidy with some support from staff. Good risk assessments were seen for each individual and included any control measures that may be necessary. For example there were clear instructions as to what staff should do if an individual became abusive towards other people. Staff said they were clear that they are at the home to support people to do whatever they wish to do within a safe environment. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to complete communications boards and use these to enhance people’s understanding and to give them more choice. Forge House DS0000067786.V350127.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, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from being offered a good variety of activities and social opportunities that enrich and fulfil their lives. Meals are nutritious and balanced and offer a healthy and varied diet for everyone. Individuals’ rights are respected and recognised within the home affording them as much independence as possible. EVIDENCE: It was clear throughout the visit that there are good relationships between people living and working at the home. People were treated kindly and with respect and there was lots of laughter and chatter. Photographs of which staff are on duty are displayed on a board to let people know which staff will be at the home each day. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 14 Due to limited verbal communication skills most people were unable to talk about leisure, social or educational pursuits. However, one person did speak with us for a short time, and decided not to out with others to take someone to visit their family in Bristol. Staff have a good knowledge of peoples needs, likes and dislikes and try to arrange activities to suit these needs and preferences. Activities available include walks, swimming, shopping, horse riding, visiting clubs, pubs, cafes and many more. Art & craft sessions are held in the home as well as therapeutic activities such as massage sessions. Relatives said opportunities for activities in and out of the home continued to improve. One relative said that their relative in the home now went out and about much more and occasionally went out in the evenings. Staff told us about their relationships with the people they care for. One was able to describe good practice in relation to ensuring people’s choice was respected and of the need to be creative in ensuring they were always given options. Another spoke about their role in building the confidence of someone to enable them to use the computer in the local library. There is a daily record of activities for everyone and it is recorded if people do not take part in the activity. However, there is little detail of how much people enjoyed the activity or what was actually done during this time (see Standard 6 also). On the day of the visit several people went out into the local town and others went to Bristol. Others helped staff prepare meals for everyone. Staff were seen throughout the visit chatting and helping people with their personal care. Discussion with the manager about evening activities indicated that these have improved and now take place more often. However, these are usually still planned activities because staff find that people (because of learned behaviours) are still tending to want to be home by about 9pm. The manager said that they are working toward changing this pattern. The staff shift pattern has changed only slightly, but there are now two day staff working till 9pm on two evenings a week. One relative was spoken with and was very positive about the care their relative receives. They said that they had previously thought about moving their relative but were now so happy about the care at the home they were going away for Christmas for the first time ever. They also said that they were always kept informed about any changes with their relative, who was always happy to return to the home following a stay with them. One person has recently been supported to obtain their own mobility car as they were unable to use the home’s transport so opportunities for outings were limited. On the day of the visit this person went out shopping in their own car, supported by staff. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 15 Menus are compiled by staff using their knowledge of peoples likes and dislikes. A series of photographs are displayed on a board to show all meals for the day. We sat with everyone for lunch, which was soup and rolls, people were able to help themselves to more if they wished. People helped themselves to drinks and fruit or yoghurt afterwards, and the meal was relaxed and unhurried throughout. Snacks and drinks are available at all times and people were seen helping themselves during the visit. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to continue to work with people on an individual basis to ensure their goals are met and to continue to offer more choice and new activities. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have an good understanding of the personal support needs of individuals, and people benefit from the very positive relationships they have with staff. To ensure the safety of individuals, all medicines are stored securely, administered appropriately, and good records maintained. EVIDENCE: The preferences of people relating to their personal care needs are clearly documented on their care plans. Staff showed a good understanding of people’s needs and were able to describe good practice in relation to maintaining their privacy and dignity and were seen to offer personal support in a polite and discreet manner. Each person living at the home receives very individualised care that provides the support they need whilst helping to maintain their independence. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 17 Health care needs are highlighted on the care plans which contained records of visits by GP’s, opticians and dentists, and include any instructions to staff following these visits. It was possible to see how people had been supported at visits to hospital and where changes in medication had improved the quality of life for one person. Medication is supplied in a monitored dosage system and boxes and bottles. It is stored in a trolley, which is secured to the wall and kept in a locked room. Only staff that have received training administer medication and their competence is checked by the home on a regular basis. Medication records were accurate, and all handwritten entries were are now signed to show they have been checked by two staff, thus protecting people’s welfare and safety. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to ensure all new staff receive training in the administration of medication, and to continue with monthly audits. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately and individuals are protected by staff who are able to recognise abuse and know their duty to report poor practice. EVIDENCE: There is a clear and simple complaints procedure for the home that sets out the procedure to be followed if a concern is identified. People living at the home have limited verbal communication and it is very difficult for someone with no knowledge of their communication methods to find out when they are unhappy. However, staff know people well enough to know if they have any concerns, and how to deal with issues raised. Some people who live at the home can indicate when they are unhappy and one person told us what they would do if they were unhappy. No complaints had been received either by the home or the Commission since the last inspection. Staff said and records confirmed, that they have recently completed POVA (Protection of Vulnerable Adults) training and felt confident that they would recognise if abuse was occurring. They were able to describe differing types of abuse and gave appropriate answers as to the steps they would take if they suspected abuse was occurring, including contacting outside agencies. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 19 All service users have individual bank accounts and benefits are paid directly into these accounts and standing orders are set up to pay fees. Good records are kept of all financial transactions with good auditing processes, ensuring that service users are protected from financial abuse. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to continue working with Care Managers, relatives and other professionals to ensure that the best quality care and support is provided to everyone who lives at the home. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an adequate standard of décor throughout and ensures that individuals generally live in a safe, homely and comfortable environment. However, many improvements still need to be made. EVIDENCE: A full tour of the building was made and it was clear that improvements are being made. However, plans are having to be re-made and timescales reorganised as major issues continue to be identified. Major problems with drains have recently been identified and the company decided to replace the system rather than repair small areas. This has meant that plans to replace the kitchen, carpets and fit radiator covers amongst other things have had to be put on hold. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 21 Some areas have been re-decorated including part of the upstairs corridor and some bedrooms though some areas are still looking a little shabby. However, the owners have now employed a full time maintenance man who is addressing any issues as soon as they arise, and a monthly audit of the home is undertaken to ensure any risks are minimised. All bedrooms are for single occupancy and reflected the personality of the individual. We were told and shown how one person now has some personal items in their room following staff working with them, when previously they would not tolerate any items in their bedroom. Where necessary adaptations have been made to ensure people that need it have the specialist equipment necessary to maximise their independence. Communal space within the home consists of a large lounge and dining room off the kitchen. The owners have recently started work on a sensory room so that people can have somewhere else to go to relax. There is a large secure garden to the rear of the home and the owners are looking to make the front garden secure, so that people could use this area safely. The home was clean and there were no unpleasant smells around the home. There is an infection control policy and procedure for the home and there were disposable gloves and aprons in several areas around the home. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to complete the works in the home necessitated by structural issues and then renovate the kitchen and redecorate the main lounge. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well trained and generally available in sufficient numbers to meet the needs of the individuals living there. The procedures for the recruitment of staff are robust and offer protection to individuals. EVIDENCE: The staff rota shows that there are generally four staff on duty until 8.30pm and two staff awake at night. However, two evenings each week staff stay on longer to enable planned evening activities to take place later than 8.30pm. A review of staff training was recently undertaken and training needs were identified to ensure service users’ needs are met consistently and safely. All staff have now completed units 1 & 2 of the Learning Disability Award Framework (LDAF), these are normally induction units for new staff and provide basic knowledge of the care necessary in learning disabilities services. However, the owners felt it would be useful for all staff to receive this training Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 23 and qualifications, even those who have already achieved National Vocational Qualifications (NVQ). Currently four staff have obtained and four staff are working towards NVQ Level 2 or above. This will take the percentage of staff with this qualification to over 50 , which is the standard that needs to be obtained. The induction process uses the ARC system, which meets the Skills for Care standards, ensuring that the basics of all aspects of care are covered during the member of staffs’ first few weeks at the home. Two staff were spoken with during the visit and they told us of the training they had received, including POVA (Protection Of Vulnerable Adults), Moving and Handling, Epilepsy, Total Communication and Autism. However, there has been no training provided on the implications of the Mental Capacity Act 2005, this means that staff are unaware of their duty of care under this new legislation. Three staff files were inspected, all contained the required information, which included proof of identity, application forms, two written references and copies of training certificates. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to employ additional bank staff for the home and employ more staff when there are any shortfalls. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed resulting in practices that generally promote and safeguard the health, safety and welfare of people living and working there. EVIDENCE: Annie Leinster (manager) has many years of experience in the care sector and in managing staff. She has obtained a level 3 in NVQ, completed the Registered Manager’s Award and intends to complete NVQ 4 in care. Staff and relatives spoke highly of her and one relative said that ‘Annie is brilliant – she really gets things done’ also that she ‘tells us everything- we a Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 25 re kept very much involved. Staff said that they felt supported to do a good job. Regular meetings are held with staff, relatives and care managers, news letters are produced for relatives and care manager to help keep them up to date with any changes in the home. The Responsible Individual for the home carries out monthly visits to the home, where inspections of records, including financial records, observations, and environmental checks and talking with those living and working at the home takes place. Reports are produced and copies are sent to the Commission. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that Forge House complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. Policies and procedures are not always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce risks to staff and service users. So that the risk of burning from hot surfaces is minimised, there is a programme to ensure all radiators within the home are covered. All windows above ground floor level are fitted with restrictors or are high openers, in order to minimise the risk of any resident falling from these windows. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to continue to review systems and adapt where necessary and to introduce more quality assurance systems that will include a complaints procedure using symbols. Forge House DS0000067786.V350127.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 3 5 X 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 2 25 3 26 X 27 X 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 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 Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA6 Good Practice Recommendations You should ensure there is more detail written on daily notes relating to activities, so that there is good evidence showing people have taken part in the planned activity. You should ensure that the premises are a comfortable and well decorated place for people to live in. 2. YA24 Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 © 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 Forge House DS0000067786.V350127.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!