Inspection on 15/07/05 for Foxlydiate Mews, 1

This inspection was carried out on 15th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Foxlydiate Mews, 1 09/12/06

Foxlydiate Mews, 1 08/01/06

Foxlydiate Mews, 1 21/12/04

Foxlydiate Mews, 1 08/09/04

Foxlydiate Mews, 1 30/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 1 Foxlydiate Mews 1 Foxlydiate Mews Lock Close, Batchley Redditch, Worcestershire B97 5LQ Lead Inspector Penny Wells Unannounced 15 &19 July 2005 18.30 & 9.15 th 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. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 1 Foxlydiate Mews Address 1 Foxlydiate Mews, Lock Close, Batchley, Redditch, Worcestershire B97 5LQ 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) 01527 60482 01527 61840 Home Farm Trust Mrs Jean Carol Hackett Care Home 5 Category(ies) of LD (5) registration, with number of places 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: In addition to those referred to on the previous page, the following condition applies: 1. The home is primarily for people who have a learning disability but may also have an associated physical disability Date of last inspection 21 December 2004 Brief Description of the Service: 1 Foxlydiate Mews is a modern, purpose built establishment in a residential area of Redditch, Worcestershire. The property is close to the town centre. The home provides a respite care service for younger adults who have a learning disability and some of whom may have a physical disability. The main aim of the service is to offer planned respite care for up to five individuals between the ages of 18 – 65. The home aims to promote a philosophy of care that recognises and responds to the individual rights and needs of service users. The manager and staff also provide a service to five tenants living in houses in Foxlydiate Mews. The registered providers are Home Farm Trust Limited, (HFT), whose head office is in Bristol. HFT provide care services nationally to individuals with learning disabilities and their families. The registered manager is Mrs Jean Hackett and the responsible individual is Mrs Mina Malpass. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection that took place during the evening of 15th July 2005 and the morning of 19th July 2005. The inspector had not visited this home previously and spent time preparing for the inspection and five hours at the home. The focus of this visit was to get to know the service and meet the five guests (referred to guests rather than service users) staying. The service offers planned short stays to 24 guests and all the places are funded by Worcestershire Social Services. Four of the places are for planned stays and the fifith place for emergencies. Time was spent with the guests, staff, viewing the home, observing and reading documentation. As the manager was off duty and the inspector new to the service, a second visit was arranged to meet with the manager. The manager explained that the house and grounds are owned by Bourneville Village Trust, who lease it to Worcestershire County Council (Social Services). Home Farm Trust (HFT) are contracted by WCC to provide the service. The service is open 51 weeks, usually closed for the last week of the year. The manager also explained that the service was set up for guests with a mild to moderate learning disabilty, who may also have a physical disabilty. However it was apparent from this visit, and the manager confirmed, that guests needs were often more complex. The inspector appreciated the welcome, co-operation and time of the guests, staff and manager. What the service does well: Provides care and support to 24 guests for short stays or in an emergency, to give their families a break. The house is kept bright, clean and safe with a welcoming atmosphere. One of the guests liked coming to the home to meet other people of the same age, to go out with them and staff, to interesting places. The other guests appeared happy, settled and were enjoying using the activities in the home in particular the sensory room and patio area of the garden. The guests were well supported by a high number of staff on duty. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 6 Two positive comment cards from parents and one commented they were pleased with the service and social life for their daughter. What has improved since the last inspection? 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. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,4 The home had information about the service for prospective guests and their representatives but it needed to be reviewed and updated. The introductory process was service user led and relevant information obtained to ensure that the needs of an individual could be met. EVIDENCE: The home had a combined statement of purpose and service user guide, which was written for prospective guests’ families and carers. The document gave a picture of the service and quality assurance system. However it needed to be reviewed to include all points listed in the standard, Regulations 4,5 and Schedule 1 of The Care Homes Regulations, and updated with changes of some persons’ names. Consideration should be given to the service user guide being in different formats for the guests. It was pleasing to see that the complaints procedure was in a pictorial format. Four prospective guests were being considered and were referred by the Social Services short-term break panel. The home had it’s own assessment form and requested a copy of the social worker’s assessment, prior to considering a person for short stays. During introductory visits, the home’s own assessment form was completed by staff. The sample files viewed, of prospective guests, had this information and additional information regarding their specific, individual needs which had been discussed with their parents. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 9 Introductory visits were flexible and arranged to suit the individual and their family. A short stay was planned once the service user seemed comfortable visiting the home. The home also had a useful form for parents/carers to complete for each stay to update the service on any changes to the service user’s needs and indicate the belongings the person was bringing into the home. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9,10 Information was being kept to ensure that the guests’ assessed needs were known to the staff and consistent care was provided. The risk assessments should be developed to cover all risky situations. Guests were involved in making decisions about their daily routines. The guests’ personal files need to be kept in a lockable place. EVIDENCE: Each service user had a file containing information about their care needs, daily routines, assessment and useful contact numbers. A sample of files were viewed and one service user showed me her file but was not familiar with it. Contact sheets were completed by staff, and in discussion with the guests, the manager advised. There were various charts available to log if a service user had a specific problem. The manager advised that reviews were annual unless a service user’s needs changed - an example was given. Also the parents/carers completed forms for each admission to update the staff on any changes, in particular health care 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 11 matters. However the files viewed did not have a record of reviews being carried out six monthly or when circumstances changed. Personal centred plans (PCP) were being drawn up for some of the guests at their day centres and the home were involved in this process but had not received a copy of a completed plan. HFT were also introducing staff to the PCP process and there was guidance in the office. HFT also had a new care planning format but this had not yet been implemented at this home. Plans should be drawn up and agreed with the service user, their family/carers and professionals involved. Wherever possible the plans should be in a suitable format for the guests and held by them during their stay. Risk assessments had been undertaken and were filed separately. These assessments should be completed for the admission of a service user and developed further to cover other risky situations – for example bathing, going out, night-time, entering/using the open plan kitchen. During the day, guests with higher dependency needs were either with a member of staff or closely monitored. At night the home had sleeping in staff. Hence it was recommended that individual risk assessments were carried out to identify whether there were any risks to guests at night. The majority of guests, with the support of staff, were involved in making decisions about their daily routines. A service user was able to make her own decisions and staff respected this. The guests’ files were on a shelf in the office with the door wide open, so consideration should be given to keeping these personal records in a locked cabinet or the office door kept shut and locked when not in use. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15,16,17 The guests, with staff support, were able to be involved in a variety of activities in and out of the home. The lifestyles and rights of the guests were respected. The guests were offered a choice of meals, drinks and snacks with individual preferences and diets catered for and mealtimes unrushed. EVIDENCE: The guests all have day centre and/or college placements during the week and were encouraged to attend if staying at the home during the week. There were a variety of activities in house including television, music, games and a sensory room. The latter was popular with some of the guests staying. In contrast a service user was enjoying watching her favourite television programmes in her bedroom. The garden patio area was also being used. Staff were proactive in arranging outings at the weekends which had included visits to Cadbury World, Think Tank, Sea Life and the airport in Birmingham. Local outings to Arrow Valley lake, the cinema, bowling, pubs were said to be 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 13 popular. The following day the guests and staff were going to the local community ‘Cool by the Pool’ summer event and hosting the tombola. The home would benefit from having it’s own vehicle as taking a group of guests, some of whom are in wheelchairs, on the bus or train needs to be planned carefully and it is difficult for outings to be spontaneous. Likewise loaning a bus from Social Services or another organisation need to be booked and an approved mini bus driver on duty in the home. The guests’ contact with parents/carers was maintained whilst they were staying. The parents/carers also supported the home in social and fund raising events. Monies from a recent sponsorship were going to be spent extending the patio, raised flowerbeds and a swing. The routine in the home was relaxed, calm with guests being able to move freely about the home and choose whether they wished to have company or be alone. The staff communicated with the guests in a pleasant and respectful manner, involving them in conversations that were taking place. Staff explained that meals were prepared according to the dietary needs, likes and dislikes (which were known) of the guests who were staying. Hence menu plans were not kept but a record of food provided and eaten by each service user were kept. On the evening of the visit rice and pasta meals had been prepared followed by raspberries, jelly and cream. A variety of drinks and fruit were freely available. Staff sat with, and assisted, guests at mealtimes in an unrushed manner. Staff still needed training in food hygiene (previous requirement). 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 The guests were receiving appropriate support with their personal and health care needs, which were identified and recorded in their plans. EVIDENCE: Many of the guests need assistance with their personal care, which is indicated in their care plans. Personal care was being provided in private, unrushed, and staff were aware of the importance of maintaining the service user’s privacy and dignity. This was observed at this visit. The guests’ appearances reflected their own choices with regard clothing, make-up and hairstyles. Some of the guests had their own walking aids/wheelchairs, which they brought with them. A service user was being encouraged to walk using her frame. The guests health care needs were also outlined in their plans and known to staff. Emergency contact numbers were recorded in case a service user became unwell. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 15 It was pleasing to note that epilepsy protocols were written up and agreed with parents/carers. Staff had been trained by a specialist nurse to administer an invasive treatment, when necessary for a seizure. The medication system was not fully inspected on this occasion and will be viewed by the pharmacist inspector next month. However the following was observed: • The guests’ medication was kept in a locked filing cabinet, in the office, with the medical administration chart. • Two staff collected medicines from the office to administer to guests who were in the communal rooms. Medicines were placed in unmarked containers and staff signed for the medication before they had observed the service user take it. A member of staff explained that if a service user refused medication, the chart would be marked with an asterisk and a record made. • The home did not have a medicines trolley or carrying case. • The home had installed a controlled drugs cupboard and a separate record of the controlled drugs was being kept. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The home had a suitable complaints procedure and it was evident that any concerns or complaints raised were taken seriously. Staff observed, listened and responded to the guests in a positive manner. EVIDENCE: The home had the HFT complaints procedure and the procedure was also in a suitable format for some of the guests. The title of the Commission needed updating. The manager advised that there had been one complaint since the last inspection (CSCI had been informed), which had been initially investigated by herself and was now being concluded by HFT. The complainants had been informed of the preliminary findings. Various steps had been taken in the home to tighten up procedures so that a similar error does not occur again which was most reassuring. However the actions taken in response to this complaint were not documented in the complaints file. This issue was a previous requirement and how this could be implemented was discussed with the manager. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 17 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) 24,25,27,28,29,30 The house was homely, comfortable, clean and well maintained for the guests to live in. The rooms, space, facilities and equipment were suitable for the guests using the service. EVIDENCE: The home is a ground floor, purpose built house situated on a residential estate in Redditch and near the town centre. There are shops, community centre and bus route on the estate. The premises were homely, bright, clean, well maintained and comfortable for the guests. The communal areas consisted of a lounge, sensory room, quiet/visitors sitting room, open plan dining room and kitchen, and laundry. Staff facilities consisted of an office, toilet, and sleeping room. At the end of the building was a resource centre, which was self contained, with own entrance and used by various outside groups. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 18 The garden was enclosed and a reasonable size. However only a small area of the garden, outside the communal rooms, could be used by the guests because the rest of the garden was on a slope and had established trees. The manager advised there were proposals to extend the patio area which would be welcomed. There was garden furniture on the patio. There were five single bedrooms, two were suitable for guests with severe mobility problems. These had special beds and tracking overhead for hoisting. The bedrooms were all suitable in size and furnishings. It was pleasing to hear that wherever possible guests were given the same bedroom. The bedrooms were colour coded and guests records linked to this for easy reference. The bedrooms had televisions and call bells. There was a spacious bathroom with specialist bath and tracking, a shower room and separate toilet. The premises were suitable for guests with severe mobility problems –wide doors and corridors, various aids and equipment, as previously commented upon. However this did not deter from the homely environment. The hot water supply was said to inadequate for the home and after one bath the hot water would run out. The manager advised that the boiler had been checked by engineers, on various occasions, but the hot water supply had not improved. HFT were discussing this issue with SS and Bourneville Village Trust. Three previous requirements had been met relating to maintenance, infection control training and protective clothing: • HFT have employed a maintenance person who visits this home regularly and carries out repairs, as observed on 19th July 2005. • Protective clothing was said to be in the bedrooms and bathrooms, with tabards being used if staff were working in the kitchen. Staff appeared to be covering all duties, so need to be mindful to wear appropriate clothing for the different tasks – cooking, cleaning or assisting with personal care. • The staff were completing an (distance learning) infection control course. Other matters relating to safe working practices in the home have been commented upon on page 23. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 19 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) 33,35 The service users were being supported and cared for by a suitable number of staff, the majority of whom knew the service users and were experienced. EVIDENCE: There were four staff on duty who were experienced, trained and knew the service users well. One of these staff was also working for some part of the evening in the flats. The fifth person was an agency worker who confirmed that she liked working in this home with the guests and had undertaken training in safe working practices through her agency. The rotas were available and confirmed that the home had a permanent staff group of 13. The home were currently short of five staff - vacancies and some sickness in the staff group. The manager advised that the home was about to appoint new staff but there was a delay in obtaining Criminal Record Bureau (CRB) checks. This delay needs to be followed up by HFT, as it was said that an applicant, with the delay in commencing work at the home, may find alternative work. The staffing levels have been increased because more guests have dual disabilities/complex needs. The rotas reflected this, according to the number and needs of guests staying at the home at any one time. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 20 At night there are two staff sleeping in. The manager was aware that this needed monitoring and would refer back to the short break panel if she considered a guest needs regular assistance at night (waking staff). The risk assessments for guests at night would therefore be beneficial as outlined on page 12. There were no ancillary staff except for the HFT maintenance person. Care staff therefore covered domestic duties - cooking, cleaning and the laundry. The staff on duty had undertaken training in safe working practices (see page 23) and training in caring for people with learning disabilities. For example person centred planning, epilepsy, communication. They were currently completing a course on infection control and hoping to do food hygiene. Two permanent staff were undertaking an NVQ in care, level 2 or 3 and two relief staff were said to have an NVQ in care. The standard recommends that 50 of the staff (including relief and agency) should have achieved an NVQ in care by the end of this year, 2005. One member had completed LDAF induction training. It is hoped that this LDAF induction training will be offered to the new staff. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,42 This respite service was being well organised by an experienced manager to ensure that the service users’ best interests and safety were paramount. Aspects of safe working practices needed attention. EVIDENCE: The registered manager was experienced, with appropriate knowledge and skills. She had just completed the Registered Manager’s Award. The manager advised that an HFT assistant service manager visited the home regularly but reports of these visits were not being sent to CSCI, as required. The standard on Safe Working Practices is wide ranging and the following was noted on this occasion: • Moving and handling assessments were carried out by a senior member of staff and recorded but she was not a trainer in moving and handling. The staff on duty had received training in moving and handling. • Infection control – staff were undertaking a distance learning course and the manager hoped this would be completed by the end of August 2005. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 22 • • • • • • • • • • Food hygiene training was proposed once staff had finished their infection control course. However this would take some time to complete through a distance learning package from college so the manager agreed to look at arranging a day’s course in-house. This would be preferable because food hygiene training was an outstanding requirement. First Aid – four staff on duty had certificates. Consideration should be given to risk assessing whether there was adequate cover on each shift or whether there needed to be a qualified first aider (a four day course) on duty at all times. Fire Awareness – An evacuation had been staged in April and a training session was being planned within the next few weeks. The manager was reminded that all staff need to receive in-house instruction in fire precautions every three months. The records of checks on the fire safety equipment were up to date and equipment was serviced annually. The visual check of the fire detection system should be carried out monthly instead of quarterly. The fire risk assessment needed to be reviewed dated and signed. Also it should be reviewed when a new guest starts staying. The manager advised that a system had been introduced for testing and recording temperature of the hot water outlets, which was a previous requirement. However the records could not be located. A legionella assessment had been carried out and the two recommendations needed to be implemented. A gas safety check had been undertaken and certificates were in place for all the gas appliances (previous requirement). The portable electrical appliances appeared to have been tested on 13.01.04 and the annual check was overdue. Also records of the tests needed to be kept. This was a previous immediate requirement and another immediate requirement was left with the manager for these tests to be carried out. A certificate of electrical safety could not be located and the manager agreed to follow this up. 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 23 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 3 x 3 x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score x x 2 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1 Foxlydiate Mews Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 2 x E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 1 9 10 Regulation 4,5,6 13 17 Requirement The statement of purpose and service user guide must be reviewed and updated. The risk assessments must be developed to cover all possible risky situations. The service users personal records must be kept securely in the home in a locked cabinet or locked room. Any complaints made to the home must have a record kept of the actions taken to invesitgate the concern and the outcome. (previous timescale of 31.01.05 partially met) The hot water system must be improved to ensure there is a continual supply of hot water in the home. The home must fill the vacancies so that the home has a permanent staff group. Staff must complete infection control training. (previous timescale of 31.03.05 partially met) All staff must receive food hygiene training before preparing food for service users. (timescale of 31.03.05 not met) Timescale for action 31.10.05 31.10.05 31.10.05 4. 22 22 30.09.05 5. 24 23 30.09.05 6. 7. 33 42,30 18 13,18 31.10.05 31.08.05 8. 42,17 13,18 30.09.05 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 25 9. 42,24 13 10. 42 13 11. 12. 42 42 13,23 13 13. 43,41 26 Hot water outlets must be tested regularly and a record kept, which is available in the home for inspection. (timescale of 31.01.05 partially met) Portable appliance testing must be undertaken and a record kept. (immediate requirement notice of 21.12.04 not met). The fire risk assessment must be reviewed, signed and dated. A certificate of electrical safety, carried out by an industry accredited engineer, must be in the home and available for inspection. The person carrying out the monthly visits on behalf of the registered provider must send a report on the conduct of the care home to CSCI in accordance with the requirements of Regulation 26. 31.08.05 31.08.05 31.08.05 31.08.05 31.08.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard 1 6 14 35 42 42 42 Good Practice Recommendations The service user guide should be in suitable formats for the service users. A process to formally review the service user plans six monthly or as needs change, should be introduced. Consideration should be given to the home having a mini bus with wheelchair access. 50 of the staff should have an NVQ in care by the end of 2005. The recommendations in the legionella assessement should be implemented. The member of staff carrying out the handling and movement assessements may benefit from further training. The manager should check and record that all staff are receiving quarterly in-house instruction on fire precautions. E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 26 1 Foxlydiate Mews 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 Page 27 Commission for Social Care Inspection The Coach House, John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 1 Foxlydiate Mews E52 S18489 1 Foxlydiate Mews V240862 150705.doc Version 1.40 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. 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