Inspection on 26/01/06 for Francis House

This inspection was carried out on 26th January 2006.

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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Francis House 11/11/08

Francis House 22/01/07

Francis House 16/11/05

Francis House 11/03/05

Francis House 02/06/04

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

CARE HOME ADULTS 18-65 Francis House Cofield Road Boldmere Sutton Coldfield West Midlands B73 5SD Lead Inspector Alison Stone Unannounced Inspection 26th January 2006 01:00 Francis House DS0000016992.V279860.R01.S.doc Version 5.1 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 Francis House DS0000016992.V279860.R01.S.doc Version 5.1 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. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Francis House Address Cofield Road Boldmere Sutton Coldfield West Midlands B73 5SD 0121 354 7772 0121 354 7772 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) Lisieux Trust Mrs Kathleen Beechey Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The establishment may provide personal care to residents under the age of 65 years. The home may provide care for 9 service users with learning disabilities. 16th November 2005 Date of last inspection Brief Description of the Service: Francis House is a purpose built modern property in the style of a large residential dwelling and is owned by the Lisieux Trust. The home is registered to provide accommodation for nine persons with learning disabilities. The Lisieux Trust is a voluntary organisation based upon a Christian ethos, however this does not preclude service users or staff from a non-Christian background to receive a service or obtain employment. The home is furnished and maintained to a high standard with service users involvement in choosing décor of both their individual rooms and communal areas. All bedrooms are single occupation, service users are supported to rise and retire when they prefer. Communal areas are situated on the ground floor with bedrooms on the first floor. There is no lift facility within the home and all service users are required to be fully mobile. To the rear of the home is a garden, which is well laid out and includes adequate seating facilities. There is sufficient off road parking for the home’s own vehicle and a further four vehicles. The home is situated in a side road and has easy access to local amenities including shops, cinema, banks and public houses. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced visit and was undertaken over one afternoon by one inspector. The inspector, collected information to form the basis of judgements in this report in a number of ways; she spoke with the people who live there, the staff, and service user and staff records were looked at, along with records relating to the management of the home, like some medication records and some health and safety records. This report should be read alongside the report of the previous inspection of 16 November 2005. The inspector would like to extend her thanks to everyone who helped with this inspection. What the service does well: What has improved since the last inspection? The manager has worked hard in a short space of time to meet all of the requirements of the last report. Staffing levels have improved since the last inspection, and there are in mostly all circumstances a 2 staff to 9 people ratio, in the home. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 6 Consideration needs to be reviewing the staffing, on a regular basis to ensure this ration remains adequate to meet the needs of the people who live there, particularly as peoples needs change as they get older. Care planning documentation is reviewed regularly now, at least every six months. The manager has contacted the Trust’s head office and requested that reference requests are made more expansive and detail the nature of the people prospective staff will be supporting. 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. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 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 Francis House DS0000016992.V279860.R01.S.doc Version 5.1 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 the following standard(s): 2, 4, 5 Service users can be confident that their aspirations and needs will be met and they will be given good support and help to choose whether they want to live in the home. Service users are supported with a contract, detailing their terms and conditions of their stay in the home. EVIDENCE: The service users who live at Francis House are a well-established group, who have been living together for a number of years. The home has a Service User Guide and Statement of Purpose, which the service users are given a copy of. The staff support service users to make their own decisions and this is further supported by a robust risk assessment process. Although there have been no service users moving in or moving out recently, discussions with the manager confirm that any prospective new service users would be given, support and information and have lots of opportunities to ‘test drive’ the home before making a decision to move in. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 9 All service users are supported with an initial assessment before they move in carried out by the social worker, then service users are offered regular reviews to ensure staff are fully aware of there changing needs. On the three files sampled, all service users had individual contracts detailing exactly what their terms and conditions were in the home, although holiday arrangements were not included. It is recommended that these contracts be amended slightly, to include details of holiday arrangements for service users, including staffing and what costs service users have to pay, if any. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 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 the following standard(s): 8, 9, 10 The manager and staff at Francis House, work hard to ensure service users are consulted with, and participate in all aspects of their life in the home. Service users are supported by risk assessments to lead as independent lifestyle as they are able, although this could be further developed to ensure service users are supported by a robust risk assessment process. Service users can be confident that information about them is handled appropriately, and that their confidences are kept. EVIDENCE: Service users are supported to be involved and participate in all aspects of their lives at Francis House, they benefit from regular service user meetings, which are independently facilitated. The service users were having a meeting on the evening of the inspection, and a number of service users said that they enjoy these meetings and find them helpful. Service users files sampled, demonstrated that there were regular reviews taking place and these were of a multi-displinary nature, the manager said that there was a delay on one service users review and this was because they Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 11 wanted to wait until their family were able to come to the review as well and they were currently on holiday. Service users files had in place monthly key worker and service users meetings minutes, where all aspects of the service users support needs was discussed with them. It was noted that these were not always happening monthly. The manager said it may be the case that they were not on file as they were being typed up. The manager said the service users have full access to the complaints policy and procedure and all have been given their own copy, which has been explained to them in detail. The manager was also going to put comment/complaint postcards in the activity room, so service users would be able to make complaints independently, without the need for staff support. The service users are also supported by an activity co-ordinator, who meets with all of the service users monthly to discuss what activities service users would like to take part in. Service users were seen to be taking an active role in their home, and some were helping make tea whilst the inspector was there. As part of the inspection three service users files were looked at. These were all found to have care plans and risk assessments in place, to support service users with their needs and ensure they were able to take risks in a safe way. However, it is recommended that these be further developed to ensure the care planning and risk assessment process fully promotes and protects service users health and well-being. Care plans should be developed more to detail, where needs are identified, there should be detailed individual care plans in place for those needs, clearly detailing to staff what action is required to meet the needs of the service users. Care plans in turn should be cross-referenced to risk assessments that then easily direct the reader from one to another. This will support service users to have comprehensive packages of support. The areas during the inspection that were noted as requiring further development, were service users night time regimes and supporting service users who bathe independently. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 12 Work to develop care plans and involve other health care professionals with a service users whose needs have recently changed with age, is taking place. The manger said this will be kept under constant review, and the need to assess his changing needs is taking place. The service user would benefit from a number of assessments, including skin care and nutrition. The manager said that these were underway, and she was looking into purchasing further specialist equipment for him, to support his needs. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 Service users are encouraged and supported to enjoy a range of developmental, meaningful daily activities. They are encouraged to be part of their local community, taking part in a range of leisure and social activities and have meaningful relationships with their family and friends. EVIDENCE: Service users enjoy a number of activities of their choice during the day; some go to college and/or work placements. The service users benefit from a large activity room in the house, which has a choice of many activities, like a TV, computer, board games and a snooker table. This is well used by the service users and one-service users said he particularly enjoys playing snooker. One-service user was on her way to work when the inspector visited. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 14 All service users are encouraged through regular meetings to talk about what activities they would like to take part in and are given support to do so. Many of the service users attend local clubs in the areas, like Gateway and prayer meetings. The service users go on holiday at least once a year and often take part in day trips around the area. The manager said that the Trust is very supportive of service users activities and gives service users £60.00 a month towards taking part in activities. One-service users had been out that morning buying art material, as this was a big hobby of hers, she then later went out again supported by staff, to go and buy some flowers and visit the crematorium. A member of staff said she was supported to go and visit her mother’s grave as much as she liked, and this often helped her when she became upset. The manager said the service users are encouraged to maintain friendships and some of the service users have close links with service users at Lisieux House, and visit on weekly bases. One-service users talked about how much she enjoyed doing this and about the friends she has there. The manager said that many of the service users stay with their families on the weekend. It is recommended that the manager look into supporting each service users to have an individual Person Centred Plan, as outlined in the Governments National Strategy, ‘Valuing People’. This would enhance the existing person centred approaches to work around activities offered to the service users. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 21 The provision of signed individual ‘intimate personal support plans’ ensure service users receive personal support in the way they prefer and require. Service users are supported to have their physical and emotional needs met, through the care planning process. The aging, illness and death of a service user are planned for, ensuring in this event it would be handled as the service user wished. EVIDENCE: On each of the service user files sampled, there was noted to be in place, a signed intimate personal care plan. Care plans sampled all detailed care needs around service users personal care, some of these were very detailed, whilst others were brief and all care plans would benefit from being consistently detailed. It is recommended that in circumstances where service users bathe independently care plans and risk assessments are cross referenced, ensuring risks around potential scalding accidents are thoroughly assessed and all measures taken to prevent this from happening. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 16 The manger discussed plans to convert one of the bathrooms into a walk in shower, this would mean, that a bath has to be removed to accommodate this. This conversion is to ensure the staff can meet the needs of all the service users who live in the home and would mean there is still a bathroom with a bath and another shower. Whilst this will not require the manger to apply for a variation and is in keeping with the standards, it is suggested that this proposal be discussed with the service users. On the files sampled it was noted, that service users are supported to attend a wide range of health related appointments, like chiropody, district nursing, GP, opticians and the dentist. Service users are weighed monthly and this is recorded in their files. It was discussed with the manager that, whilst there were no concerns in the area of service users being supported with their health needs, they would benefit from having individual Health Action Plans. This would ensure all service users had their health needs assessed, and that plans of care and health goals could be developed from these assessments, these could then be reviewed regularly as apart of the service users six monthly reviews. This would support service users to have proactive plans of care in respect of their health and ensure and signs and symptoms of changes in health could be quickly identified. Work has been undertaken with individual service users to consult with them and their families about their wishes in the event of their death. Work is in progress with one service users, supporting him and offering guidance in the changes he is experiencing because of his age, which is leading to health problems. This work needs to be further developed in the area of illness and the aging process for all service users and could be something that is incorporated into well woman and well man groups, supporting service users to recognise changes in their health and how to cope with these and would be an area that forms part of the Health Action Plan process. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users can feel confident that their views are listened to and acted upon. Service users are protected from abuse, neglect and self-harm, by trained staff and robust policies and procedures. EVIDENCE: There have been no complaints since the last inspection and the manager is now displaying a stock of post cards for the service users use anonymously within the home, to enable service users to make complaints independently. Service users are encouraged to raise concerns and complaints at the service users meeting, the manager and I discussed expanding the complaints procedure to include compliments and comments, so positive things about the service from service users, relatives and others could also be recorded. The manager said that she would take this to the next service users meeting to discuss this idea. The manager said, staff have all attended protection of Vulnerable Adults Training, this needs up dating every two years and staff need to attend a course in this area within six months of being appointed. The three staff files sampled, demonstrated that staff have attended training in this area. Three service users financial records were sampled during the inspection. Service users files demonstrated accessible and detailed records of how service Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 18 users receive their money and what bills like rent they have to pay for, and what money is left over for them. The manager said each service users has a financial risk assessment record in place, to protect service users from financial abuse as much as they are able. It was recommenced where service users are able they should be encouraged to sign up to all financial risk assessments demonstrating their understanding and agreement. However one-service users file indicated that he had bought a wheelchair, this is not an appropriate expenditure of service users money, and service users contracts detail that the Trust will buy any required specialist equipment. There was also nothing in place on the service users file to indicate the purchase of the wheelchair followed an assessment by an occupational therapist or physiotherapist detailing, which sort of wheelchair would best support the service users needs. It is required that the service users have this money reimbursed to his account, and the manager refers the service users to his GP for an assessment from a occupational therapist as to what sort of wheelchair he requires, this can then be provided by the NHS or the Trust. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 29, 30 Service users are supported to live a homely, comfortable, spacious environment that was in an excellent decorative order and is clean and hygienic. The bathrooms and toilet areas provide a pleasant private area to meet the service users personal care needs. Service users are supported to have the specialist equipment they require to promote their independence. EVIDENCE: During the inspection a tour of the premises was undertaken, and all shared space was looked at. The decorations of the home and the furniture and fittings are of a high standard and the service users said that they helped chose the decorations in the home. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 20 There were lots of personal items reflecting the interests of the service users around the home that are sympathetically kept, so as not to appear as an intrusion on shared areas. The bathrooms are pleasant and allow service users privacy to carry out their personal care needs. There are plans to convert one of the bathrooms into a walk-in shower; this will allow staff to continue to meet the changing needs of all the service users in the home. This will still leave a further shower and bathroom with bath upstairs, providing service users with a number of choices about how they would like to wash. It is recommended before this conversion takes place that the reasons for doing this are discussed with the other service users. Service users are supported to have the specialist equipment they need, and currently the environment is more than able to meet the needs of the service users who live there, however this needs to be kept under constant review to ensure as service users needs change adaptations and alterations are made as required to support service users changing needs. The home was found to be very clean and hygienic on the day of the inspection. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 The staff team are well supervised and supported and benefit from clear roles and responsibilities. The staff team have competent and qualified to carry out their duties and support service users effectively. More training in specialist areas would be beneficial to service users and staff. The staff team remains small, which could pose problems for covering all shifts and there is currently a vacancy for a 40 hour senior post, the management of the home would benefit from this post being filled. Service users are supported and protected by the homes policies and procedures in the area of recruitment. EVIDENCE: Three staff files were sampled during the inspection, these were found to demonstrate regular staff supervision, new members of staff had regular monthly supervision during their three-month probation period. Files generally meet with schedule 2 of the Care standards Act 2002, however one file only had a the persons birth certificate in place, staff files needs to include a copy of a birth certificates and a copy of a passport. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 22 The manger said staff have regular meetings at least four to six weekly. A new member of staff said she really enjoyed working here, and the organisation was good at supporting her training needs and since starting work the staff team had been very helpful to her in getting to know the service users. Staff spoken to spoke with motivation and commitment about their job and clearly enjoyed working with and supporting the service users in the home. Over 50 of the staff team had achieved their NVQ 2 or above. The manager is the lead in the organisation for arranging training and refreshers for staff, staff files and the training matrix indicated training was up to date in statutory areas. The training matrix would benefit from detailing which organisation provides the training to staff. Although the requirements do not specify that training should be annual, it is important that this is given consideration in some areas like first aid one day courses, manual handling, COSSH, In house fire training and Health and Safety, as guidance in these areas in constantly changing and being up dated. Annual training in some areas in the only way a manager can be confident that the staff team is working within required safe practices. The staff team would also benefit in areas of training that are relevant to individual service users needs, like communication, Person Centred Planning, Health Action Plans and courses around the aging process. The manager has taken action to ensure she does all she can to meet the requirement from the last two inspections, requesting the reference process is more robust and details the nature of the service users prospective staff are going to work with. However she has not appointed any new staff since she spoke to HR about this issue, so she is unable to confirm that this request has been taken on board by head office. The rota demonstrated that there were always at least two members of staff on duty at key times. The manger said that she also works a Saturday to support service users attending activities and ten of her working hours were care hours. The staff team benefits from the use of three regular agencies and bank staff, which ensures the manager is able to cover the support needs in the home on a 24-hour bases. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 23 The staff team are currently 2 posts down, one has recently been recruited too, and they are waiting for clearance checks before the new member of staff can start work. There is a vacancy for a 40-hour post in the role of a senior care worker, this needs to be filled as soon as possible to support the staff team and the manager in the management of the home. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 The service users benefits from a generally very well run home, with a consistent management lead. The manager has an open, approachable and supportive style of management. Service users can be confident that their views underpin all self-monitoring, review and development in the home The health and safety of the service users is promoted and protected. EVIDENCE: The manager has been in post several years and appears well organised and proficient in the running and management of a care home. The manager demonstrates a warm and open style of communication that the service users and staff seem comfortable with. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 25 During the inspection staff and service users alike, seemed very comfortable with approaching the manager and talking to her about any issues they had. The manager has ensured there is a quality assurance process in place, which regularly surveys the thoughts and opinions of service users and relatives; this is then put into an annual quality assurance report. The service users benefit from other systems of support to canvass their views, like independently facilitated service users meetings and regular key worker meetings and reviews. Some Health and Safety records were inspected as part of the inspection and found to be in good order, these included; Annual Portable Electrical Appliance testing, weekly water temperatures, annual Gas Land Lord Certificate, five year electric hard wiring checks, twice yearly fire drills, weekly fire tests, Legionnaire water checks and monthly vehicle checks. It was noted that water temperatures are erratic, and sometimes quite low and other times high, the manger said this is an on-going problem, which she is dealing with and is waiting for a plumber to come out and visit the home. This situation needs to be closely monitored by the manager, and should be risk assessed, to protect the service users from any accidental injury until the issue with the water temperatures is resolved. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 2 3 3 3 X X 2 X Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 27 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. 1. Standard YA9 Regulation 13(4b) Requirement The registered manger must ensure all service users are supported to have individual night-time care/support plans and corresponding risk assessments. The registered manager must ensure that all service users have comprehensive individual care/support plans, which can be easily cross- referenced with the corresponding risk assessment. Care/support plans should provide a detailed specific plan that clearly identifies support needs and actions on how these will be met. The registered manager must ensure that service users are supported to purchase appropriate belongings with their own money and the practice of buying specialist equipment for themselves must cease. The service users concerned must be reimbursed for the full cost of the wheelchair he purchased recently. The registered manger must operate and adhere to a robust DS0000016992.V279860.R01.S.doc Timescale for action 31/03/06 2. YA9 13(4b) 09/06/06 3. YA23 13 (6) 27/06/06 4. YA34 7 9 18/03/06 Francis House Version 5.1 Page 28 19 Sch2 5. YA42 23(2p) recruitment system and ensure that staff records include those items stated in Schedule 2 of the Care homes regulations for inspection. The registered manager must ensure water temperatures are checked weekly, from each water outlet and a risk assessment is put in place until the problems with the water temperatures are remedied. Service users also need to be supported to have individual risk assessment to support them to bathe independently on be protected from any accidental scalds. 26/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 1. 2. 3. Refer to Standard YA5 YA6 YA7 YA19 Good Practice Recommendations The registered manager should ensure, details for the arrangement of service users holidays be included in their individual contracts. The manager should investigate early mental health support from learning disability nursing services, both for individual service users and for training for staff. All services users need to be supported to have a Person centred Plan. The service users should be supported to have individual health action Plans. Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Francis House DS0000016992.V279860.R01.S.doc Version 5.1 Page 30 - 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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