Inspection on 14/09/07 for Gombards

This inspection was carried out on 14th September 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gombards 30/01/07

Gombards 24/05/06

Gombards 27/02/06

Gombards 04/05/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Gombards 6 London Road Welwyn Herts AL6 9EL Lead Inspector Claire Farrier Key Unannounced Inspection 14 & 17 September 2007 1:35 th th Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gombards Address 6 London Road Welwyn Herts AL6 9EL 01438 712892 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) None United Response Sheena Jean Mackenzie Bagnall Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Gombards is a purpose built home first registered in 2005. It was designed with full wheelchair accessibility and was built as two self contained units each catering for four service users with learning and physical disabilities. The home which is jointly owned by Health, Social Services and by Aldwyck Housing Association is managed and run by United Response (a voluntary organisation). The home is situated in Old Welwyn, ideally for service users to access amenities and local services. Local shops and entertainments are only a short distance away from the home. The home consists of ample bathrooms and shower rooms to meet the needs of the people who live there. There are additional aids and adaptations that include overhead tracking systems. The home is spacious and presents as a homely environment for the people who live there. The Statement of Purpose and Service Users Guide provide information about the home for referring social workers and prospective residents. The current charges are from £1,500 - 1,800 per week. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We spent one afternoon at 1 Station Road, and the people who live there and work there did not know that we were coming. The focus of the inspection was to assess all the key standards. Some additional standards were also assessed. We met and talked to all the people who live in the home, and we saw some of the things they did while they were in the home. We also talked to some of the staff. When we were in the home we looked at the records, care plans and staff files, and we made a tour of the premises. We made a second visit to the home a few days later so that we could talk to the manager about what we had seen during the inspection. What the service does well: What has improved since the last inspection? There is an ongoing programme of recruitment, and more permanent staff are now in post. This means that fewer agency staff are working in the home, and the people who live there are supported by a regular team of people they know. The home has been made safer for the people who live there. Water temperatures are now monitored to make sure that they are not too hot, and locks have been put on the cupboards where cleaning chemicals are stored. Care plans and personal files are now stored in locked cupboards on each floor. The home informs CSCI of incidents that may affect the welfare of the people who live there. They also send us copies of the reports of the regular monitoring visits that United response makes to the home. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has sufficient information on residents’ needs and access to appropriate services to enable their needs to be met. EVIDENCE: No one has moved into the home since the last inspection. At that time we saw that the referring social worker provided a detailed assessment that was updated before admission, and the home also carried out their own comprehensive assessment, which includes good information on all the person’s needs, and the process of pre-admission visits to the home. The staff said that they have sufficient information and training to enable them to meet the residents’ needs. The assessments and care plans that we saw on this occasion address the residents’ cultural and spiritual needs, and how the service will meet those needs. The service user agreement contains the terms and conditions of the services provided by the home, and the rights and responsibilities of the residents. We saw a completed and signed agreement in the files that we inspected on this occasion. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The care plans are written from the viewpoint of each individual. But one person has no care plan, and no risk assessment for the safe use of bed rails. This means that the staff may not have sufficient information to provide a good quality of care and support, and the person may be at risk of injury. EVIDENCE: We looked at three care plans, and used them to track the care and support that is provided for the people who live in Gombards. There has been no change to the care plans since the last inspection. Most of the care plans are clearly written, with good details of all the residents’ needs and procedures and guidelines for meeting those needs. The care plans have a person centred format, which emphasises and encourages each person’s independence. The care plans for personal care are written in the first person and include how to communicate with the resident, and praise for their participation. Each person’s assessed needs are detailed in Active Support Plans, with goals such Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 10 as socialising and communication. The Active Support Plans are clearly written, with good details and procedures for any actions that are needed. For example, one resident has a plan for helping to prepare a meal. The procedure includes encouraging them to wash and feel the texture of the vegetables, and stirring food. There are photographs of the resident carrying out each part of the activity. The behaviour guidelines for another person are written from the person’s point of view. For example, “I sometimes cry. I will do this when I am cross or upset, you need to find out what is wrong and try to put it right. I will do this when I want to go out – staff should follow the shift plans in place to ensure I get out enough.” The file for the newest resident, who was admitted in August 2006, had no care plan or Active Support Plans. The file contained some guidelines, for example there was a speech and language therapy assessment with guidelines for how their food should be prepared. Further details were given in the daily recording. It was not clear what the most up to date guidance was. No action has been taken since the last inspection to provide a care plan for this person, so that the staff have goof information on how to provide the support that they need. Everyone has a yearly Whole Life Review, but they care plans that we saw have not been reviewed or updated since the last inspection. Some appropriate risk assessments are in place. These are also clearly written, with good details of the risks involved and the measures needed to enable the residents to manage the risks safely. However there was no risk assessment for the safe use of bedrails for one person. On the morning of this inspection this person had become stuck with their legs through the sides of the bed. The incident report stated that the bed rails need to be reassessed, as it appears inappropriate for the person’s individual needs. But they was no care plan or risk assessment for the safe use of bedrails before this incident happened. All the residents of Gombards have limited communication, and most have no verbal communication. POWhER provides an advocacy service. None of the residents are able to take any responsibility for their own finances. The home has satisfactory procedures for managing each person’s spending money. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are encouraged to make choices for their activities, and to be involved according to their abilities in developing their skills for independence. But some people are not supported to take part in the activities that are scheduled for them. EVIDENCE: Most people attend day services three or four days a week. Outings into the local community are arranged with the residents, and the home has its own vehicle for longer trips. One the evening of the inspection several people were going to the theatre in St Albans. Records of outings are maintained in each person’s daily notes. Planning for trips occurs on the shift planner, which enables each member of staff to arrange and support the service user in making choices to attend. The activities that are currently listed include lunch out, going to the library, aromatherapy, touch and taste, cookery, board games, and writing to family and friends. Two people were out with a member Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 12 of staff during this inspection. The home has a portable sensory machine that encourages the residents to interact. Residents are encouraged and enabled to take part in daily living activities in the home. However one person has a care plan that states that they should have frequent trips outside, and the shift plans show different activities for them for each day of the week. But their daily diary recorded on three of these activities during the last week, and on most days the person “sat out in the garden” and “enjoyed music”. Everyone is supported and encouraged to meet with their families, and families are welcomed into the home. Some people have befrienders who are former members of staff, and there has been a change in the policy for supporting people to meet with them. Two complaints have been received by the home during the last month about the change of policy (see Concerns, Complaints and Protection). However the policy of supporting people to meet their befrienders outside of the home means that they have a social activity in the community rather then in the home, and should be of benefit to them. We did not observe a meal on this occasion, but during the last inspection we assessed that the menus offer a balanced and nutritious diet. There is a two weekly alternating menu, which is the same on both floors. The meals are cooked separately in the kitchen on each floor, and the daily shift planner details what should be cooked each day. One resident has pureed food, and there are guidelines in their file for preparing this and helping them to eat. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff provide good quality personal care and treat the residents with sensitivity and respect. Pressure area care is not recorded and monitored appropriately. Medication procedures are generally good, but the audits are not effective in monitoring errors. EVIDENCE: The care plans that we inspected provide generally good details of the residents’ personal care and health care needs (see Individual Needs and Choices), and a good relationship was observed between the staff and the residents. The home has a good relationship and professional support from medical professionals, including appropriate referrals for Speech and Language and Occupational Therapy assessments. One resident has a care plan for walking regularly, to enable them to become more mobile. This activity was observed during the inspection. The care plans contain guidelines for management of challenging behaviour and for epilepsy where needed. Food Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 14 and fluid charts are maintained for every resident, and they are weighed regularly. The handover file for one day shortly before this inspection mentioned that one person had a sore area and “skin rub” on their toe. There was no mention of this in the person’s daily record, and no mention of any monitoring or care needed in their care plan. Each person has a bruise chart, for recording any bruises or concerns about skin care, but this was not completed on this occasion. The district nurse visits frequently, but there was no record that this had been referred to her, or that any treatment or monitoring was in place. Any changes that may become a more serious pressure sore must be recorded, monitored and treated effectively. Medication is stored separately for the residents on the ground floor and the first floor. There are appropriate procedures for administering medication, and is a weekly audit of the MAR (medication administration record) charts and of the stocks of medication to check for any errors. The temperature in the storage cabinets is monitored to ensure that it does not go above the safe limit for storing medication. An audit of each person’s medication had been carried out on the day before this inspection, and it recorded that all medication was supplied and recorded correctly. However when we carried out a spot check of the medication for two people, we found that one person had a MAR chart for paracetamol, but there was no paracetamol available. However there was a supply of codeine phosphate for them, but no MAR chart for this medication. There was a protocol for when and how to give paracetamol. Both these medications are prescribed to be taken when required (PRN), and none had been administered during the time of the current MAR chart. This error may cause a risk of the wrong medication being administered. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home and their families and friends are supported and encouraged to make their views known. But complaints are not recorded affectively. Policies and procedures are in place to ensure that service users are protected from abuse and neglect. EVIDENCE: The complaints policy contains clear definitions to differentiate concerns and complaints, and appropriate procedures for investigating any complaints. A form for recording complaints has been implemented following the last inspection, but it does not record any actions that may have been taken as a result of the complaint, and whether the complainant was satisfied with the outcome. Two complaints have been received by the home during the last month. One was from a social worker, and one from a former member of staff. Both addressed concerns about befrienders visiting the home. (See Lifestyle for further details.) the complaints were dealt with appropriately, but during the process there may have been insufficient communication with one of the complainants. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 16 All the staff have received training in prevention of abuse as part of the company’s comprehensive induction programme. The support workers are aware of their responsibilities and the procedures for reporting any concerns. A few days before this inspection an allegation was made about a member of staff. Proper procedures were followed to ensure that the people in the home are safe, and the incident is currently being investigated. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and well-maintained environment for the residents, and the staff maintain a good standard of cleanliness. EVIDENCE: The building is detached house. It was designed and newly built for the service and it is situated on an access road behind Old Welwyn High Street. It was built as two self contained units each catering for four service users with learning and physical disabilities. It is furnished and decorated in domestic styles that produce a homely, comfortable environment, which allows the residents to relax and feel at home. The residents all have their own rooms, arranged and decorated to reflect their particular interests and tastes. The lounge, dining room and kitchen are domestic in style and are comfortably furnished and well equipped. There are plans to create a sensory room in the bedroom on the first floor that is no longer required for staff to sleep in. The home has a small garden that is accessed from the ground floor lounge. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 18 The home has appropriate equipment for the residents, including track hoisting in the bathrooms and lounges, and in the bedrooms of the residents who need it. One resident has a specially designed toilet seat, and several residents have their own specially designed seating systems and wheelchairs. The home is generally well maintained, and the hoists and lifts are serviced regularly. In the five months from March through to July there were nine recorded incidents of problems with leaks, lack of hot water, and lack of heating. The boiler that was installed when the home was built is a specialised system, and an expert plumber was needed to address the issues. The boiler has now been serviced and the heating system has been rewired, and there have been no further incidents concerning the heating and hot water. Cleaning materials, including stain remover, kitchen cleaner and disinfectant, were seen in unlocked cupboards. (See Conduct and Management of the Home.) The home appeared to be clean, and the staff follow appropriate procedures to maintain hygiene and prevent the risk of infection. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is staffed by sufficient support workers to meet the needs of the residents. The staff files do not provide satisfactory evidence that each person is fit to work with the vulnerable people in the home. EVIDENCE: The staff who were spoken to feel well supported in their work, and said that they have the training and information that they need to provide a good quality of care for the residents. Staff rotas show that there are five or six support workers in the home during the day and evening, and two waking night staff during the night. These levels are adequate to meet the complex needs of the residents. The daily schedules are very detailed, and specify which support worker will provide care or support for each resident for all periods throughout the day. This ensures that the residents’ assessed needs are fully met as described in their care plans. There is an ongoing programme of recruitment, and more permanent staff are now in post. This means that fewer agency staff are required. At the time of the last inspection there were no permanent staff on some shifts, but the number of agency staff has now Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 20 decreased to a maximum of three or four each day. Everyone said that the management and the other staff are supportive to the new staff, and they have good information from the shift plans and care plans on what to do each day, and what each person needs. United Response provides comprehensive training for staff that covers all mandatory training in first aid, moving and handling, fire safety, food hygiene, etc, and training to meet special needs the residents have such as epilepsy and behavioural problems. There is a comprehensive induction programme that includes 5½ days of mandatory training. Due to the changes in the staff group and the large number of agency staff, the number of support staff with NVQ qualifications is very low. Only one support worker and the two deputy managers currently have NVQ qualifications. The company is aiming to ensure that all the staff have completed their mandatory induction training, and they should then register for NVQ training. Funding is now available for everyone to undertake the training for the qualification. The manager said that the recruitment procedures followed by the company are robust and that he sees all the information on each applicant during the recruitment process. The staff files of two members of staff were inspected. Neither had evidence of a CRB (Criminal Record Bureau) disclosure. It was reported that these are kept at United Response head office. But there was no record in the staff files to show that satisfactory disclosures had been received before each person started to work in the home. One file contained only one reference, and the other had an application form that showed unexplained gaps in their employment. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed in some areas of record keeping and maintaining a safe environment. The quality assurance system does not include an effective way of obtaining the views of the residents and their families, which is essential to underpin all selfmonitoring, review and development of the home. EVIDENCE: The manager was appointed in October 2006. He was deputy manager at another United Response home for three years. He has completed NVQ level 4 in Health and Social Care, and he has registered for the Registered Managers Award. He is qualified as a NVQ assessor and as and moving and handling trainer. A second deputy manager has been appointed since the last inspection. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 22 The home maintains appropriate records for the health and safety of the residents and staff in the home, and staff generally follow the home’s policies and procedures. The regular audits in the home include a monthly hazard check of the premises. However improvements are needed in some areas of record keeping and maintaining a safe environment. These were also noted during the last inspection. 1. A fire risk assessment has been completed and the fire drills include a full evacuation of the premises. However the names of the staff who take part in the fire drills are not recorded, and there is no evidence that each member of staff takes part in a fire drill at least once a year. 2. Cleaning materials, including stain remover, kitchen cleaner and disinfectant, were seen in unlocked cupboards. The store cupboard on the first floor landing was unlocked on both days of the inspection. The cleaning supplies cupboard under the sink in the first floor utility room was unlocked during the first afternoon of the inspection, but had been locked securely at the time of our second visit to the home. The cupboard under the sink in the first floor kitchen was unlocked for an hour, at a time when there were no residents in the area. In addition to stain remover and chemical cleaners in this cupboard, there was an Evian water bottle containing a blue liquid, and marked “Rinse Aid”. The risk to the people who live in the home may be reduced as the cupboard was locked when they were in unit. But there is a considerable risk of serious harm from using a drinks container for harmful chemicals. Chemicals must be stored in the original marked containers, and must be stored securely at all times. United Response has established a robust system for quality assurance, which includes quarterly service audits of the home, with recommendations for any actions needed. However the process does not include the views of the residents, relatives and visiting professionals. At the last inspection it was reported that the manager contacts all the residents’ families regularly. All the residents have very little or no verbal communication. The staff understand their needs, and record how they appear in their daily diaries. These contacts with relatives and residents are not formulated and recorded as a tool for monitoring the quality of care in the home. Gombards DS0000063291.V339010.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 15(1) Requirement A care plan must be in place for every resident, that provides details of the person’s assessed needs and the procedures for meeting them. A previous timescale of 31/05/07 was not met. Appropriate and adequate risk assessments must be put in place for all residents for situations in which there is any risk of harm or injury to themselves or others. The staff must support each person to take part in their choice of social activities in the home and in the community. The registered person must liaise with the district nurses to ensure that appropriate care plans and recording are in place for the management of pressure area care. Measures must be put in place to ensure that medication is audited effectively, and that any errors in medication are noted and rectified without delay. Timescale for action 29/02/08 2. YA9 13(4) 29/02/08 3. YA14 16(2)(m) 29/02/08 4. YA19 12(1)(a) 29/02/08 5. YA20 13(2) 29/02/08 Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 25 6. YA22 22(8) 7. YA32 18(1)(c) 8. YA34 19(1)(b) 9. YA39 24(3) 10. YA42 13(4)(a) 11. YA42 23(4)(e) The registered person must ensure that a record of complaints is maintained in the home, which shows the process of investigation, the outcome, and any actions taken as a result. A previous timescale of 31/05/07 was met in part. Measures must be put in place to ensure that all members of staff are given the opportunity to take appropriate NVQ qualifications. A previous timescale of 31/07/07 was met in part. All the required information on staff, as listed in Schedule 2 and Schedule 4(6) of the regulations, must be kept in the home, including references and evidence of satisfactory CRB checks. A system for monitoring the quality of care must be established, that focuses on the consultation with the service users and other involved people, and provides feedback on the process and the results of the consultation. A previous timescale of 31/07/07 was not met. All substances that may be hazardous to health must be stored properly and securely at all times. A previous timescale of 05/02/07 was not met. The names of staff taking part in fire drills must be recorded to ensure that every member of staff takes part in at least one fire drill a year. A previous timescale of 31/05/07 was not met. 29/02/08 29/02/08 29/02/08 29/02/08 29/02/08 29/02/08 Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Gombards DS0000063291.V339010.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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