Inspection on 19/02/08 for Foxdown

This inspection was carried out on 19th February 2008.

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

Foxdown 23/02/07

Foxdown 23/02/06

Foxdown 08/09/05

Foxdown 08/03/05

Foxdown 04/11/04

Foxdown 02/03/04

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Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Foxdown Paley Street Nr Maidenhead Berkshire SL6 3JT Lead Inspector Ruth Lough Unannounced Inspection 19th February 2008 12:15 Foxdown DS0000047598.V357851.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 Foxdown DS0000047598.V357851.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. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Foxdown Address Paley Street Nr Maidenhead Berkshire SL6 3JT 01628 776507 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) s.humphrey@owl-housing.org Owl Housing Ltd Mrs Barbara Susan Humphrey Care Home 6 Category(ies) of Learning disability (0) registration, with number of places Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 6. Date of last inspection 23rd February 2007 Brief Description of the Service: Foxdown is a six bedded detached bungalow situated in a quiet location in Paley Street near Maidenhead. The home caters for the needs of people with learning and associated physical disabilities some of whom may display challenging behaviours. All service users’ bedrooms are single occupancy and have been decorated and arranged to different tastes. Communal areas are spacious and bright and the home overlooks countryside. The aims and objectives of the home are to provide 24 hour care and support, promoting equality and independence in accordance with the individual’s needs and aspirations Fees for the service were £1278.56 per week, according to previous information supplied by the home. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people who use the service experience good quality outcomes. This was an unannounced key inspection process generated by the adequate findings from a visit to the home in February 2007. The inspection process included information submitted to the commission in the Annual Quality Assurance Assessment, self-assessment document completed by the manager prior to a one-day visit to the service. Relatives, staff and health and social professionals were also given the opportunity to comment about the service through surveys returned to commission. Five were returned in total. The inspector observed the interaction between service users and staff and their general wellbeing during the day. What the service does well: What has improved since the last inspection? The staff and manager of the home had identified that some of the residents were missing out on opportunities to attend activities and develop their interests because of difficulties with transport. To rectify this they have purchased a new passenger vehicle with a ramp that can take wheel chairs. This has made a tremendous impact on the flexibility of arranging and supporting service users to continue and develop their activities. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 6 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. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 7 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 Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 8 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has processes in place should a vacancy arise to admit a new individual to the home. EVIDENCE: The service has an assessment of need process in place should a vacancy at the home arise. The home has not admitted a new resident since it’s opening in 1999. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 9 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, and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual needs and choices of the people who use the service are being met. EVIDENCE: All five respondents to the survey thought that the needs of the people who use the service are being met. Some of the comments from relatives included; “ They do a marvellous job with my brother,” and “ They have been brilliant with him and meeting his needs.” Comments from professionals were; “The staff at Foxdown are very good at tailoring to the needs of the individual,” Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 10 “ The standard of care is extremely high and the needs of the individuals take priority. The staff have a good understanding of the differing needs of each resident and react and respond appropriately.” The records for two people living in the home were reviewed to assess if staff are provided with sufficient information to support and meet the individual’s needs. The care records seen provide staff with a brief summary of personal, health and learning needs the individual may have, and any professional and relatives contact details. The persons care planning needs are divided into different topics ranging from personal care to communication. Some of the information is more detailed in places and there are accompanying documents outlining identified risks and giving instruction of how staff are to support them. A key worker is responsible for each individual’s care planning and for seeking their involvement where possible with its development. The content of some of the information seen did give the impression that the staff had a good idea of the person concerned, choices, and wishes. During the last inspection process it was identified that some of the care planning documents had not been reviewed or updated for a considerable time. This has now been rectified and the records that were seen had been reviewed and updated during the last year. Each individual has been provided with a copy of a document called an Essential Lifestyle Plan, in which their important needs, choices and wishes are outlined in a format that may meet the communication needs of the person concerned. The deputy manager has already commenced reviewing and redeveloping the document tools for all the care planning and the essential life plan that is given to the residents as to improve the content and offer greater clarity of information. The personal risks and the risks to others from the individual are identified in the care plan records. There were two documents for the risk assessment processes found in the care files reviewed, and it was unclear what format the home were using to provide information to staff. Both documents were good at providing information about the identification of possible risks but there were some weaknesses in parts to show how staff are to eliminate or reduce the risks. What was apparent through discussion with staff and observation of their working relationships with the individuals they are not recording in the care Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 11 records fully the support they carry out or the actions they take to minimise any risks. If they improved the information in these records this would assist other staff, such as agency or bank staff to be able to provide better continuity of care. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 12 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. The people who use the service are able to experience new activities and to take part in the local community. EVIDENCE: Relatives in the survey were asked to comment about if they thought that the service was meeting the needs of the person receiving support. One relative stated; “Until my brother went into Foxdown, he was very withdrawn and very frightened of anyone who didn’t wear a white coat and would run away when family visited him. Since being there has become an individual in his own right, been on holidays, gone out for meals and we have discovered that he does have a level of understanding which we never knew.” Another comment in regard to activities was, “ Just recently my brother has been on an activity holiday where he did absailing, and canoeing. I think he really enjoys himself, which is important to him.” Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 13 The service users and staff who spoke to the inspector did provide information that there was usually busy programme of activities and educational opportunities for all the people living in the home. From photographs and these discussions it appears staff have supported the residents to enjoy having holiday breaks and day visits. These have included new experiences like physically active holidays at specialist centres where people with learning and physical needs are enabled to try sporting activities. The home has also supported friends and family to join in activities and celebrations the home. However, the staff in the home should ensure that they improve how they show they have consulted the service users on choices for these activities in the individual’s assessment and care planning records. They should also record in greater detail the personal outcomes for each individual as to provide supporting evidence that the activities meet the needs, ambitions, and choices of the person concerned. Copies of some risk assessments were seen in regard to holidays and trips for individuals in a central file, but nothing was noted in the care planning to indicate that these had been completed. Information in the care records about what the activities the residents are assisted with at the Day Centre, evening clubs and external interests to the home is brief and did not give a clear picture of what they are supported with. The staff and manager of the home had identified that some of the residents were missing out on opportunities to attend activities and develop their interests because of difficulties with transport. The location of the home in a semi- rural environment meant that there was a limited bus service plus it was also not appropriate at times for wheelchair users or those with limited mobility. To rectify this they have purchased a new passenger vehicle with a ramp that can take wheel chairs. This has made a tremendous impact on the flexibility of arranging and supporting service users to continue and develop their activities. Service users are supported to have a variable diet that is matched to their needs and choices. Meal and menu planning has been developed around staff acquiring knowledge of personal preferences and professional guidance to meet particular health needs of the individual. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 14 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, 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service are supported to maintain their personal care and access professional healthcare support and treatment when required. EVIDENCE: The care records reviewed show that service users are assisted in varying degrees, in accordance to their needs, with their personal care. They also show that the staff continue to encourage the individual to learn new skills to maintain their own personal care needs. The deputy manager provided information that although some of the service users were physically disabled the majority were in good health and had not required treatment for any major health needs. The records reviewed that the service users are supported to access treatment for dental, eye care, and foot care needs on a regular basis. Visits to the GP and clinical specialists are also recorded well with the outcomes of all consultations and treatment noted. One resident receives regular support from the Surgery Nurse that includes staff being entrusted to carry out routine monitoring of the individuals health with a specialist task. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 15 Most of the information about an individual’s health is noted in separate documents in the care planning records but there is not a process of bringing the information together for monitoring the individuals overall health. What they could do is to develop a process of recording the significant health events in a central record that would give staff an opportunity to identify any patterns of health needs. The deputy manager did state that the provider organisation is already looking at improving the monitoring and management of service users health and accessing treatment when required and to develop the service users involvement of the process. The staff monitor regularly each persons weight and have sought professional advice when significant changes have occurred. The home has policies and procedures in place for the safekeeping and administration of medications for the service users. None of the residents are able to self-administer medications themselves so staff take full responsibilities for this. The manager provided information in the Annual Quality Assurance Assessment, self-assessment document that there had been three episodes of medication administration errors during the last year. This highlighted concerns about the staff’s knowledge and skills and a training programme for all staff was implemented to improve this. The training has been completed and medication administration is now included in the induction programme for all new staff. The records of administration were reviewed and the deficits highlighted in the last inspection process for recording any medication administered have now been rectified. Staff are recording accurately on the MAR (medication administration records) charts. As previously stated, staff carry out a health-monitoring task on behalf of an individuals Surgery Nurse. The deputy manager provided information in regard to how this was managed and was able to evidence the specific training undertaken by some members of staff to do this. However, she was unable to provide a copy of the information/ instruction in regard to cascading the training to other members of the staff working at the home. They are advised to obtain another copy of this consent as supporting evidence before continuing with the training programme. The needs of the people who use the service in regard to ageing, illness and care at their end of their life was discussed as the care planning records did not support that their personal choices had been explored or recorded. The deputy manager did state that this was something that they may possibly include in the planned review of how they manage meeting the needs of the service users in the future. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 16 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. The people who use the service and others concerns are listened to and acted upon. Service users are protected from possible harm or abuse. EVIDENCE: The relatives who responded to the survey confirmed that they knew of the complaints process and who to speak to if they had concerns. The professionals also confirmed that they thought the staff acted appropriately if concerns were raised. Information about how to make a complaint about the service is included in the Statement of Purpose and Service User Guide documents. This information is also provided in a written and pictorial format suitable to meet the needs of the individuals living in the home. Staff record in the individual’s daily record any expressions of dissatisfaction that services users give which for the majority is through non- verbal communication. Visitors and relatives who come into the home are encouraged to record in a comments book any concerns or compliments. Two visitors had used this to compliment the staff and about the support they provide to the residents, and there were no complaints noted during the last year. The manager confirmed in the Annual Quality Assurance Assessment, self-assessment document that the service had not been in receipt of any complaints about the service since Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 17 the last inspection process. The commission has not received any information, comments, or complaints in that period, also. The home has policies, procedures, and information to guide staff to ensure that service users are protected from possible harm or abuse. The policy and procedure directs staff to the local interagency policy should an incident occur. Staff are provided with training within the induction and training programme. The deputy manager confirmed that they take responsibility for managing some of the service users personal finances. Each resident has their own bank account and there is a limited number of senior staff that are responsible for accessing money on their behalf. The records used to manage the finances of two residents were reviewed to assess if safe practices are carried out and protect service users money. The records seen showed that staff are recording in detail with receipts any transactions or money spent. The deputy manager stated that all records were audited by the provider organisation. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment of the home meets the needs of the service users and is kept clean and pleasant to live in. EVIDENCE: One professional wrote about the home; “Foxdown provides a home for its residents. It has a warm and friendly atmosphere and relaxing environment with well maintained and accessible grounds.” The home is not purpose built but was converted from a private family home for its current use. The home has generously proportioned bedrooms and communal spaces that provide the residents the freedom to live together without infringing each other’s personal space. The house is set back from the main road running through the village and has plenty of parking spaces to the front of the building. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 19 The garden is to the rear and one side of the building, provides views across open fields, and has plenty of space for the residents to enjoy the outdoors within a secure environment. Care has been taken to ensure that the garden and the internal structure of the building are accessible to those with limited mobility or use a wheel chair. There are two bathrooms, one with an assisted bath, and one with a bath and shower. One of the bedrooms has an en- suite toilet and shower. The inspector was informed that the shower unit in the communal bathroom was under review and the intention is to improve access for some of the service users. Each of the other bedrooms has a washbasin should the resident require it. The flooring around the toilets was showing signs of wear and tear and could possibly make it difficult to manage the control of infection as changes in the fixtures and fittings have left areas exposed. Through discussion it was identified that not all the bedrooms have a call bell system fitted. Staff are aware of this but were able to evidence that this is of concern at present as the occupants are able to communicate sufficiently should they need assistance. However, it is something that they plan to improve in the future as resident’s needs change. The home generally is kept well maintained with carpets, fittings, and fixtures in good condition. A recent programme of replacing the original fitted wardrobes in five of the resident’s bedrooms has now taken place, with the last bedroom wardrobes proposed to be renewed in the near future. Even with the home having rooms of a good size and a large communal space there is a problem with the storage of equipment such as a hoist and electric wheel chair. The deputy manager was advised to review the current practices of ‘parking’ these items in the entrance lobby of the home as to improve access to the resident, staff and visitors. The home has a separate laundry area that is positioned away from any food preparation area. Staff support residents where able to take some responsibility for washing of their clothes and therefore the make the laundry room accessible to them. During the previous inspection process the home were required to make a hot pipe/ flue safe as it was open to service users coming into contact with it and putting them at risk of burning themselves. The home did render this safe swiftly after the inspection process. However, on the day of this inspection visit the safety measure had been removed and not replaced the previous day by the responsible landlord who was carrying out repairs. The deputy assured the inspector that this in the process of being replaced, subsequent contact with the home staff confirmed this was carried out the day after the inspection visit. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a consistent team of care staff who have been recruited safely and provided with the necessary training to meet the needs of the people who use the service. EVIDENCE: A comment from a professional who comes in contact with the home was very complimentary about the staff. “The staff team is stable and consistent and it is obvious that the residents benefit greatly from this and built strong relationships.” A carer provided information in the survey that they thought that the home provides sufficient training and that they had regular supervision. They also added that they always have regular handover each shift to catch up with any changes in care and support and have regular team meetings. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 21 The home has a team of staff that is fairly consistent. Since the last inspection process the have been two new members of staff employed one who was transferred from another home owned by the provider. The records for recruitment and employment of staff were reviewed to see if the home uses robust recruitment practices and provides the necessary training and support to the staff. The records seen for the recruitment process were copies of some of the documents used for checking identity, including current driving licences. A document with the required information about the staff member, such as address, references obtained, Criminal Records Bureau check and a summary of their work history has been put by the provider with the supervision records for the individual as supporting evidence that the recruitment practice has been carried out appropriately. The inspector did not request to view any other documents, such as the original records held at the provider’s head office, with reference to this, as sufficient information was available. Through discussion with staff and the information provided by the manager prior to the inspection visit is was apparent that residents were involved with the interview and recruitment processes for new staff. Very little was seen in the records viewed to support this. Through discussion with staff and a review of the records in the home its was identified that new staff are given a structured induction programme that is continued through their probationary period of employment of six months. Records of the training given to staff were seen with the majority of the training provided relevant to health and safety topics and the retraining for medication. Moving and handling training was also included for all staff as this was of concern previously that some staff were providing support not in accordance to the planned care for one service user. This has been a focus of the training in the recent twelve months to ensure that staff have an updated knowledge to transport and assist service users safely. The deputy manager stated that recent small changes in some service users health have indicated that staff would benefit from further training in some of the relevant topics such as diabetes. The manager provided information that over 60 of the staff employed in the home have obtained qualifications of an NVQ 2 or more, in care. The staff appear to be provided with a regular programme of formal supervision with good records kept of any meeting or discussions that take place. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 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 managed well and in the best interests of the people who use the service. EVIDENCE: A GP commented about the service overall, “I feel that the level of care is excellent.” One relative wrote, “ Everything,” and another put, “It’s a very peaceful and happy home.” They added further, “ We are very happy to entrust our relative to Foxdown, he has come on leaps and bounds.” The home is managed by an experienced manager who is supported by a deputy manager and a number of care staff who have been working in care for Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 23 a considerable length of time. Some of the staff have been supporting one or two of the residents previously before they came to live in the home. The manager was recently registered with the commission in November 2007 as suitable for the role she undertakes, having previously been the registered manager for another of the providers homes in the area. She has obtained an NVQ4 and RMA (Registered Managers Award) and other professional care qualifications during the period of the previous role. The home has some processes in place for monitoring the effectiveness of the services they provide and obtaining some feedback from residents where able. They are not able, because of the needs of the people who use the service to use formal questionnaires, but they have found other methods to measure service users opinions of the service. This is through the regular reviews of care and recently the service user meetings. For staff this includes routine ‘handover’ meetings at the change in shifts and regular staff meetings. The provider also ensures that monthly monitoring visits, in accordance to Regulation 26, are carried out and any findings are passed back to the manager should action be required. The deputy manager provided information that the information from these processes was being used within the business planning for the next financial year. The home has a programme of training and information is provided to staff for safe working practices. They also have systems in place for ensuring that the residents and staff are protected from harm through a regular maintenance programme of the electrical, gas and water systems used in the home. The information included in the Annual Quality Assurance Assessment did give indicate that the required servicing of equipment and the systems for fire have been carried out during the last year. A sample of the information for fire safety and the risk assessments for the general environment were reviewed to see if they have been carried out appropriately. No concerns were raised but they were advised to develop further the fire risk assessments for each individual resident to assist fire officers support them should they need to escorted or assisted from the building should a fire occur. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 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 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X 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 2 3 3 X X X 3 X Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. 2. Refer to Standard YA9 YA14 Good Practice Recommendations That they improve the information in the risks assessment documents to give better instruction of how to eliminate or reduce the risk. That the staff include greater information of how they have consulted with service users on choices for activities and record in greater depth the outcomes for the individual in regard to enjoyment and participation. What they could do is to develop a process of recording the significant health events in a central record that would give staff an opportunity to identify any patterns of health needs. The home is advised to look at improving how they store some of the equipment in the lobby of the main entrance to the home as to ensure that it does not restrict or obstruct residents to move around the home. It is recommended that they look at how they can improve the flooring around the toilets in the home as to minimise the risk of cross infection from the areas exposed to DS0000047598.V357851.R01.S.doc Version 5.2 Page 26 3. YA19 4. YA24 5. YA30 Foxdown 6. YA42 moisture. They were advised to develop further the fire risk assessments for each individual resident to assist fire officers support them should they need to escorted or assisted from the building should a fire occur. Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone, Kent ME16 9NT 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 Foxdown DS0000047598.V357851.R01.S.doc Version 5.2 Page 28 - 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. 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