Inspection on 02/08/05 for Gallaudet Unit

This inspection was carried out on 2nd August 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

Gallaudet Unit 11/04/07

Gallaudet Unit 16/11/06

Gallaudet Unit 14/06/06

Gallaudet Unit 06/02/06

Gallaudet Unit 14/03/05

Gallaudet Unit 06/09/04

Gallaudet Unit 06/01/04

Similar services:

5 Seafield Road

Honeybourne House

Longrun House

Bodley Community Care Support Centre

Thomas Pocklington Trust

Chantry Gardens

Penkelly House

25-27a Alexandra Road

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

CARE HOME ADULTS 18-65 Gallaudet Unit RNID Poolemead Centre Watery Lane Twerton Bath BA2 1RN Lead Inspector Gillian Underhill Unannounced 2nd & 23rd August 2005 09:30 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. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Gallaudet Unit Address RNID Poolemead Centre Watery Lane Twerton Bath BA2 1RN 01225 356487 01225 480825 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) RNID Mrs Ruth J Young PC Care home 8 Category(ies) of SI Sensory Impairment (8) registration, with number of places Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 8 persons aged 18 to 64, requiring personal care. Date of last inspection 14-Mar-2005 Brief Description of the Service: The Gallaudet unit offers 9 single rooms to accommodate deaf people with special needs,including those with moderate physical disability. The environment is a single storey building surrounded by attractive gardens and grounds. The unit , which is part of a large complex incorporating other units,has its own clearly defined philosophy of care which aims to embrace varying levels of independence and autonomy where each person is encouraged to achieve their full potential as adult members of the wider community. The unit employs a team of support workers,all with a range of sign language ability and experience. All bedrooms have a wash hand basin.Service users are able to lock their door if they wish,and a small number of people have a key to their room. Although the Gallaudet unit is not tailored to meet the diverse needs of the service user group,and space is of a premium,work will commence in due course to extend bedrooms in order to provide even greater opportunities for independent living. Recently the lounge area has been extended and now offers greater space for service users to relax in. All meals are now cooked on the unit and extended dining room space has been provided. . Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence of this inspection (which was conducted over 2 days) was gathered by observation of a selection of the unit’s policies and procedures, discussion with the deputy manager, and six of her staff team, and by observation of service users. There have been no admissions to the unit since the last inspection, but one person who has been resident in Gallaudet for less than a year was consulted, and confirmed that he was reasonably happy, but is eager to move into the wider community in order to live more independently. This person said he had not been given a copy of his care plan, but would be very pleased to receive one. All other service users were observed to be extremely settled and content in the presence of staff. Some service users are unable to express their views or opinions articulately through sign language or other communication media. What the service does well: What has improved since the last inspection? From the six staff consulted during the day of the inspection, all bar one said the atmosphere had greatly improved, and the current management support and style was conducive to the general activity of the unit. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 6 The atmosphere has most certainly improved, and this was demonstrated by the relaxed manner and renewed confidence of staff. Service users also seemed very content and affable. Regular supervision is now active and staff confirmed they receive the support they need to carry out their jobs effectively. One senior support worker has been allocated the task of ensuring new people in post receive a full and comprehensive formal induction. Evidence produced and discussions held during the inspection confirmed the commitment of the senior management team toward this task. The current management approach and management style has most certainly boosted the morale of the staff team, and all feedback received during the inspection was positive and gave praise to the deputy and her acting senior support worker. What they could do better: A copy of the service users contract between the RNID and the service user must be made available to the manager. The Statement of purpose needs to contain the number and room sizes, as outlined in Schedule 1 of the National Minimum Standards. All service users reviews need to be recorded and made available for all forthcoming inspections. Care plans need to be updated, as outlined in standard 6 of the National Minimum Standards, and agreed at the previous inspection. All complaints made by service users or their relatives need to be recorded, along with any investigation, action taken and outcome. All staff should read and confirm they understand the contents of the RNID’s Vulnerable Adults policy & procedure. Linked to this, the training needs of staff regarding the Protection of Vulnerable Adults need to be reviewed, and training arranged within 3 months of the inspection for those who require it. A record of all food provided for service users needs to be kept, in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory in relation to nutrition. The staff-training matrix should be updated and maintained in good order. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 7 All night staff need to receive regular, formal supervision. A self-monitoring tool for measuring the unit’s success in achieving the aims and objectives of the unit needs to be introduced. Regular fire drills and training need to be implemented. Weekly tests of fire equipment need to be maintained. Risk assessments on safe working topics to be completed. 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. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) .1 & 5 The registered manager has produced a statement of purpose, setting out the aims, objectives and ethos of the unit. Although the document is well set out, it has not been produced in any other format, other than English word. If the statement of purpose was produced in Braille, or other suitable formats then a small number of service users would have access to the detailed information provided. It also needs some additional detail. Although there are service users contracts they are not given to the manager by the RNID: this must happen in order for the manager to know what is expected contractually. EVIDENCE: The Statement of purpose is detailed but still needs to include the number and size of all rooms. The document should also advise the reader on whether or not nursing care is provided. The statement of purpose is not in Braille or any other format other that English. The recent changes to the extended dining room and lounge have been added, to the document, which has been dated February 2005. The manager has yet to receive copies of the contract between the service user and the RNID, and therefore the specification details could not be Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 10 examined during the inspection process. This is an outstanding requirement from previous inspections. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 8 Care plans have not been fully updated to encompass all aspects of the service users strengths and abilities as agreed during the previous inspection. If care plans were produced in this way the service users level of dependence could be measured at the point of each review. Also if service users were given a copy of their plan of care in a format they can understand they or their relatives would have full details of their assessed need and the agreed outcome to achieve set goals and aspirations. Six monthly reviews need to be recorded in full detail and held on file. Service users are consulted on and participate in, all aspects of life in the home, as appropriate to their individual needs and ability. EVIDENCE: During the previous inspection the manager said that care plans were in the process of being reviewed and updated, and that a senior support worker was working on a new format for this purpose. Money management, privacy, housekeeping responsibilities and dietary needs were to be incorporated into each individual plan of care. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 12 During this inspection there was evidence that the care plan review has not been fully completed for each service user, and the documents examined were still in the transitional stage. During a discussion with the deputy and senior support worker it appeared there was some confusion over the task to be completed, which has resulted in the assessment documentation being initialised for the care planning process. On the 2nd day of the inspection the original care plans had been reintroduced, and the deputy manager said that hopefully the necessary updating as agreed at the previous inspection would be completed by the end of 2005. One service user consulted by the inspector said that he had not been given a copy of his care plan, and when asked the deputy confirmed that this also applied to other service users. None of the care plans have yet been produced in other suitable formats for those service users who would be able to understand pictorial versions of this information. One service user self harms and this information has been recorded appropriate. Risk assessments have been completed. Annual reviews have been carried out, and detailed information on this process has been recorded. The manager said that 6 monthly reviews are also carried out, but there was no written evidence of this. The inspector asked how service users participate in aspects of life in the home, and was advised that they are involved in selection of furniture and equipment, shopping and cleaning. Also each person decides on what activities he or she wish to be involved in, including Educational Development Studies. They do not contribute to the development of policies, but a one-service user frequently sits in on some staff meetings. The home receives feedback from service users on a daily basis, through their [service users] meetings, and keyworker feedback. Very little information has been provided in a suitable format for service users. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14 & 17 Service users are able to take part in appropriate educational courses with the support of their key-worker. Although an annual holiday has yet to be arranged, service users have enjoyed daily trips out, both in small groups and on a one to one basis. From evidence produced during the inspection the staff on the unit promote service users health and wellbeing by providing, varied and balanced meals, within a congenial setting. If records of all food provided were maintained, then anyone inspecting the record will be able to determine whether the service users diet is satisfactory. EVIDENCE: No one is in paid employment, or attends further education courses. One service user is considering the available and appropriate college courses for attendance in September, and one person has recently completed a City & Guilds horticultural course. There are no volunteers used in the home, or work placements. Although annual holiday have not been arranged yet, staff have organised lots of day trips, and evening outings, which said they enjoyed. On the day of the Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 14 inspection most of the service users went to a Bristol bowling alley, and out for lunch with the support workers. Just recently staffing levels over the weekend have been increased. All meals are now cooked on the unit. Staff shop with service users twice weekly. Service users select meals from pictorial menus. Each person on the unit assists with food preparation and cooking, including cake making. A food file with different types of food has been put together which service users access whenever they want ideas for new menus. A recent Environmental Health visit was carried out with a satisfactory outcome. A full record of all food provided has not been maintained. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 0 standards were assessed. EVIDENCE: Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 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 & 23 The complaints procedure, which is in symbol format, would be supportive in the event of service users making a complaint. Any complaints made by service users or their relatives must be fully recorded, detailing the action taken and outcome to the complaint, in order for the CSCI to determine whether or not service users views are listened to and acted on. The manager must make sure that each member of staff has read the RNID’s policy and procedure on Adult Protection, and knows how to make service users safe if an allegation of abuse is made when they are on duty. A unit specific restraint policy would complement the method of approach on managing challenging behaviour, and assist in increasing the awareness of staff when dealing with such issues. EVIDENCE: On observation of the complaints record no complaints had been logged, but one service user said he had complained about having to pay for meals when day trips were arranged. The service user had clearly seen this as a complaint, but no record was made of this, or how the complaint was resolved. The complaints procedure has-been updated, but reference to the “supporting people team” in connection with how complaints should be dealt with if the complainant remains unhappy should be removed from the complaints procedure. This is an outstanding requirement from the previous inspection. The complaints procedure has been developed in symbol format. The last recorded complaint was logged on the 10th January 05. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 17 An Adult Protection policy & procedure is in place, but two staff said they had not read this information, and one other person was not sure of the action they should take in the event of an allegation of abuse being made while they were on duty. From the records observed only three staff have completed POVA training. although it is acknowledged that new staff have been appointed, and others transferred to other units or have left the employment of the RNID. At the last inspection it was explained that a senior staff member was developing a restraint policy and procedure for two service users, which in time would become an accepted policy and procedure for the unit, when dealing with other service users who demonstrate challenging behaviour. A Department of Health, framework policy which includes guidance on the use of restrictive physical intervention in care settings as been used for this purpose, in conjunction with the units ‘method of approach’, which includes restraint details, and the procedure to be used. This in time will be an integral part of all service users ‘method of approach’, where appropriate. All staff receive training on Non- Abusive Psychological Intervention [NAPPI]. The deputy said that restraint training was also provided, although this was not evidenced from the training matrix, which was not up to date. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 0 standards assessed. EVIDENCE: Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 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) 32, 33, 35 & 36 Service users are supported by essentially competent and skilled staff. However training on supporting service users with a learning disability would assist staff in broadening their knowledge and awareness of issues, which may be present in such a diagnosis. The training matrix needs to be consistently updated in order for the senior management team to be able to identify any discrepancy in staff training. The recent increase in staff over the weekend period has enabled a spontaneous response to activities and trips out for service users over this period. The re-introduction of team meetings and formal supervision sessions has enabled the management team to ensure that staff fully understand the purpose of the home and the key elements that underpin the standards. EVIDENCE: During this inspection both the deputy and senior support worker were consulted in the absence of the manager who is on long-term sick leave. During consultation with a number of support workers, each person said that Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 20 they feel the team is benefiting from a more structured management approach, and that they feel the recent conflict in the unit has decreased considerably. The staff team seemed relaxed and intuitive regarding the needs of the service users. The predominant disability of the service users on the Gallaudet unit is sensory loss and learning disability, and in order to support service users, most staff are able to use sign language as a method of communicating. Currently two staff are undertaking BSL level 1 & two staff BSL level 2.One staff member has completed a Deaf Blind training course. Four members of staff have been nominated for NVQ level 3 for September 05. The deputy manager has almost completed NVQ level 4, and the senior support worker level 3. The staff member employed to carry out domestic tasks on the unit has also completed NVQ level 2. From information supplied there is every indication that there is a good skill mix of staff employed on the unit. Staff have been employed from various work backgrounds and experiences, which include transfers from other units, and the employment of students. Staff meetings are held now on a regular basis. Weekend staffing levels have recently been reviewed, and increased to meet the changing demands of the unit. The training matrix was not up to date, and therefore it was difficult to clearly establish what training had been undertaken by staff, however the deputy manger outlined training events, which staff had recently completed. One staff member has completed training on epilepsy; two on management of diabetes, one deaf blind training, five medications, three first aid, and most staff have completed basic food hygiene. The deputy has recently finished a course titled “managing transparently”, and three senior staff have just completed conflict management. Only a very small number of staff have completed sexuality training to date. Two staff said that recently lots of training had been cancelled. An RNID induction pack is used to induct all new staff, and this issue was subject to a lengthily discussion, on the pros and cons of introducing the policy and procedures of the RNID whilst continuing to manage the unit and support service users. The discussion considered the benefits of allocating this task to a designated person who’s sole task would be to ensure comprehensive coverage of the induction pack, mentoring new staff, and formalising the probationary period. On fully examination, one module in the induction pack had been signed by an assessor without any evidence being produced confirming the inductee’s competence. Staff supervision has now been regularised, with discussions and dates recorded. Annual appraisals have been completed. In total 10 staff received Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 21 supervision in June, and 10 in July. Three night staff have yet to receive supervision. Staff are given copies of the RNID’s grievance and disciplinary procedures. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39 and 42. The change in the management style and approach to staff management has lifted the atmosphere in the unit. Staff were generally optimistic and motivated, and felt that the deputies approach was conducive to a sense of well-being and progress for both service users and staff. All confirmed that supervision sessions and regular team meetings provided a platform for discussing both service user care and staffing issues, which in the past has not always been addressed. If quality assurance monitoring systems were used this would enable the management team to consolidate evidence on the units success in meeting the aims, objectives and statement of purpose for the home. It is essential that each staff member takes part in regular fire drills and training in order to feel confident in their action should a fire occur in the unit. Risk assessment on all safe working topics would ensure so far is reasonably practicable the health and safety of service users and staff. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 23 EVIDENCE: Staff consulted said there has been a recent change in the management approach inasmuch as the deputy manager, and senior support worker have made themselves more available to the team, whilst implementing formal supervision sessions, and regularising team meetings. Both senior staff said they are very clear about the need to deal with conflict on the unit as it occurs, and thus divide their time between dealing with management issues and integrating with service users and staff. There is still no formal quality assurance and quality monitoring system in place as such to measure success in achieving the aims; objectives and statement of purpose of the unit, but some methods used go some way to embracing this standard. The service manager for the units on the main Poolmead site visits Gallaudet on a regular monthly basis and carries out a detailed check; communicating with service users, staff and also discussing policy and practice issues. Service user meetings are held, and also case reviews. This goes some way to measuring the set objectives, and monitoring objectives informally. Health and Safety maintenance checks are carried out and the file was found to be in good order. An RNID health & safety policy and associated statement was examined and was in line with recommended practice. A generic risk assessment policy has been developed, and whilst risk assessment forms have been provided the deputy was unable to produce evidence that risks assessment for all safe working practice topics have been carried out. Fire drills and training for all staff are not regular and in line with the recommended practice as detailed in the Avon Fire Log. COSHH assessments were found to be in good order. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x 1 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 x 3 x x 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gallaudet Unit Score x x x x Standard No 37 38 39 40 41 42 43 Score x 3 2 x x 2 x D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 25 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. Standard 1 Regulation 4 Requirement Statement of purpose to include number and sizes of rooms,and also that nursing care is not provided. Copies of service user contracts to be given to the manager. Care plans to be reviewed and updated.Copies of care plans to be given to service users or their relatives. All reviews to be recorded. All complaints made to be recorded. Record of food provided to be kept Training to be provided for staff that have not yet received P.O.V.A. training. All night staff to receive formal supervision. Self monitoring tool to be introduced. Regular fire drills & training to be implemented. Weekly tests of fire equipement to be maintained. . Risk assessments on all safe working topics to be completed. D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Timescale for action 31/10/05 2. 3. 5 6 5 15 31/10/05 31/12/05 4. 5. 6. 7. 8. 9. 10. 11. 12. 6 22 41 15 22 17 31/12/05 31/10/05 7/10/05 23 12 30/12/05 39 39 42 24 24 13 30/12/05 30/12/05 7/10/05 13. 42 13 30/12/05 Page 26 Gallaudet Unit Version 1.30 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. Refer to Standard 36 23 35 23 35 Good Practice Recommendations All staff to sign confirming they have received supervision and agree with the written outcome to those sessions. Unit specific restraint policy & procedure to be developed. Sexuality and learning disability training for staff to be considered. All staff to read and sign to say they fully understand the contents of the Vulnerable Adults policy & procedure. Training matrix to be maintained in good order. Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 Page 27 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG 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 Gallaudet Unit D05_ D56_ S40658_ Gallaudet_V 238793_ 010805 Stage4.doc Version 1.30 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!