Inspection on 27/09/07 for Hampshire House

This inspection was carried out on 27th September 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hampshire House 14/01/10

Hampshire House 01/06/06

Hampshire House 12/01/06

Hampshire House 26/07/05

Hampshire House 23/02/05

Hampshire House 10/05/04

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

CARE HOME ADULTS 18-65 Hampshire House & Redsteps The National Society For Epilepsy Chesham Lane Chalfont St Peter Gerrards Cross Bucks SL9 ORJ Lead Inspector Jo Griffiths Unannounced Inspection 27th September 2007 10:30 Hampshire House & Redsteps DS0000022975.V337319.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 Hampshire House & Redsteps DS0000022975.V337319.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. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hampshire House & Redsteps Address 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) The National Society For Epilepsy Chesham Lane Chalfont St Peter Gerrards Cross Bucks SL9 ORJ 01494 601427 01494 871927 lyn.marks@epilepsynse.org.uk www.epilepsynse.org.uk The National Society for Epilepsy Post Vacant Care Home 20 Category(ies) of Physical disability (0) registration, with number of places Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1. The registered person may provide the following category/ies of service only: Care Home only - (PC) to service users of the following gender: Either whose primary needs on admission to the home are within the following categories: Physical Disabilities (PD) The maximum number of service users to be accommodated is 20. 1st June 2006 2. 2. Date of last inspection Brief Description of the Service: Hampshire House and Redsteps provide a rehabilitation service for people with epilepsy. The service is based in two separate buildings located at the National Society for Epilepsy (NSE) centre in Chalfont St Peter, Buckinghamshire. Hampshire House is an older building which has been extended and provides 14 places in single rooms on two floors. Redsteps is a conversion of two buildings, two semi-detached former staff houses, on the periphery of the NSE site about 400 metres walk from Hampshire House. Together the service can accommodate up to 20 younger adults with epilepsy. The homes aims include the development of service users independence. The home is an integral part of the NSE and benefits from a wide range of support services provided by the organisation. Weekly fees at the time of this inspection were between £1028 and £2750. Fees are agreed based on an assessment of the support each individual will need. At the time of the inspection Redsteps had closed as part of the modernising plan for the service. It is planned that the service will be provided in Hampshire house only and an application to change the registration of the service will be made. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection of Hampshire house. Redsteps was not inspected as it has now closed. The Manager is going to apply to CSCI to change the number of people the service can support. Hampshire house can currently accommodate 14 people although this is being reviewed by the NSE as part of their business plan. There is a new Manager in post who was at the home during the inspection visit. The Manager completed the Annual Quality Assurance Questionnaire and sent it to CSCI before the inspection took place. The Manager and staff did not know that the inspector was visiting. To help make a judgement about the quality of the service provided at Hampshire house the inspector had a look around the home, spoke to some of the people that live there and looked at some of the important records. What the service does well: What has improved since the last inspection? The Statement of Purpose has been updated to reflect the way the service is developing. Most communal areas of the home have been redecorated and there is a new bath to help people with mobility difficulties. The new Manager is now permanently in post and has been further developing the opportunities for people to access their local community. There are new systems for monitoring the quality of the service and for getting peoples views about their home. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 6 There are now better system’s in place for staff to report any concerns about peoples welfare. 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. Hampshire House & Redsteps DS0000022975.V337319.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 Hampshire House & Redsteps DS0000022975.V337319.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): Standards 1, 2, 3 and 4 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are provided with the information they need to make a decision about moving to the home. They have an assessment of their needs, an opportunity to test drive the home and are only offered a place in the home if their needs can be met. EVIDENCE: The Service User Guide and Statement of Purpose give people information about the care home. They were reviewed in July 2007, but require minor amendment to reflect the recent change of Manager. The Service User Guide is currently in written form and the Manager plans to develop this to better meet the communication needs of the people in the home. Everyone has an assessment of their needs before they are formally offered a place in the home. This is to ensure the service is able to meet their needs fully. The person is invited to stay at the service for four weeks to ‘test drive’ it And decide if it is somewhere they would like to live. This is also an opportunity for the Manager and staff to carry out a full assessment of the persons needs. Health care professionals that are based on site are also involved in this assessment. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 9 During the trial stay people are supported to try out different social and educational activities that are available on site. Clear records are kept of the things they enjoy so that this can be included in the care plan if they move in. People spoken with in the home said they were very happy with the service they were receiving. The inspector observed the support being offered generally to people’s throughout the visit. This indicated a good understanding by staff of people’s needs and preferences. The home evidenced they are able to meet the needs of people from a variety of backgrounds and with a variety of needs. Where people have developed their skills and are looking to move onto more independent forms of housing the Manager has developed transition plans. One of the tools used is the ‘Future Living Options Plan’. This helps the person make decisions about where they would like to live in the future and what is important to them when looking to move on from Hampshire house. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People have a care plan that meets their needs. People are generally supported to make their own decisions and have a say in how the home is run. Clearer records of any restrictions on people’s choices are required. People are supported to take reasonable risks as part of an adult and independent lifestyle. EVIDENCE: Each person in the home has an individual care plan. The care plans are easy for staff to follow and are kept up to date. There is a review of the plans approximately every 3 months. The plans link with the assessment of the persons needs and ensure that these needs are met. Wherever possible people have been involved in their plans and have signed them. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 11 During the visit to the home the inspector saw a number of examples of people being supported to make everyday decisions in their lives. This includes choosing their meals, how they spend their time and contacting family. The future living options plans have been implemented to help people plan moving on from the service. Some of the staff have completed training in Person centred planning. The Manager hopes to develop the care plans further to involve people more in the future. One option that is being considered is the use of audio equipment to help people make their own care plans. Monthly meetings are held for the people in the home. The minutes are displayed on the notice board for the residents of the home to see. The minutes show that generally staff support and enable people to give their views and have a say in how the house is run. One example was seen in the minutes where people were informed of changes to the keyworker arrangements rather than being involved in making the decision. This is a minor issue that the Manager plans to work on with staff. Further training for staff in Person centred planning may help them to adapt their approach to give people in the home even more control over their lives. The Manager and staff are working with individuals in the home who have limited communication skills to develop other ways they can communicate their choices. Objects of reference are being introduced. This is where an object is used to represent an activity or a need. The person is supported to use the object to communicate. During the visit it was noted that one person’s right to access some of their personal belongings at certain times of the day had been restricted. The Manager described how the decision had been made in their best interests with the consultant and how the person had been involved in this. However, there was no documentary evidence available on the care plan to support this. The Manager was advised that in any case where there are restrictions on a person’s rights there must be clear evidence of how the decision was made, who was involved, why the decision was made and when it is to be reviewed. Risk assessments have been completed for each person and some were sampled within the care plans. They are clear and support people to take reasonable risks. One example is that people’s wishes with regard to being checked at night by staff are respected as far as possible. A risk assessment is completed and they are supported to make an informed choice after being given all the information about the benefits and risks. The risk assessment is reviewed regularly based on their changing needs. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are supported to participate in the activities of their choice. They are supported to access the local community, but would benefit from more opportunities to do so for employment and education. People are supported to build and maintain relationships. They are aware of their rights and responsibilities in the home. People enjoy their meals and have a balanced diet. EVIDENCE: People have an individual timetable of activities for the week. Most of the activities are provided on site by the learning and skills team. These activities include, hydrotherapy, dance, badminton, communication and daily living skills. Some people undertake work in sheltered workshops or the laundry on site. They are paid a therapeutic wage. Full employment for people has not yet Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 13 been explored, although some links with voluntary organisations in the local community have been made. It is hoped that as people develop their independence that they will be able to make an informed choice about whether they wish to gain employment. Some people attend local college courses. Since the last inspection people are having more opportunities to access the local community to take part in activities such as using the pubs, restaurants, cinema and shops. However, there is still reliance on the activities provided on site and due to the rural location of the home public transport is not readily available. The NSE has long-term plans for the service that involves better links with the wider community. In the meantime, the Manager is working with people to support them to make use of taxis and to build their opportunities for activities away from the site. People in the home are supported to meet new people through their activities and the Manager states that should a person wish to have support to build personal relationships this could be provided. The learning and skills team provide some education for people on relationships and sexuality. People are welcome to have visitors to the home when they wish but not after 11.00pm unless this is prearranged. This is to avoid disruption to other people in the home. People are supported to attend church if they wish to. One person has prayer time undisturbed in his room. This is a good example of people’s religious needs being met. The menu is planned individually and reflects people’s cultural needs. The rules and responsibilities in the home are laid out in the Service User Guide. Respect for each other and contribution to the running of the home are discussed in the monthly residents meetings. People spoken with were aware of their rights and responsibilities in the home. People are supported to undertake a clean of their own room each week, manage their own laundry with or without support depending on their needs, and help prepare their meals. People are given a budget for their food each week. They have their own fridges/freezers and are given as much or little support to plan and prepare their meals, as they need. Some of the people that require more support have grouped their budget and plan their menu together. The kitchen is a good size and allows people to access it to prepare their meals or to observe. Two people living upstairs in the home have a kitchen between them where they cook independently. People can choose to eat in the dining room or alone if they prefer. Mealtimes are flexible depending on people’s activities. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People’s health care needs are fully met by a team of specialists employed by the organisation. They are supported with their personal care needs in a sensitive and dignified way. People are supported to manage their medication safely. EVIDENCE: People’s health needs are identified through the assessment and how they will be met is detailed within the care plan. The care plan states who is responsible for ensuring the need will be met and when it is to be reviewed. There is excellent support from the team of healthcare professionals on site. This includes access to a Consultant Neurologist, Psychologist, Psychiatrist, visiting GP, Nurses, Physiotherapist, Dentist, Chiropodist, Occupational Therapist, and Complimentary Therapists. Some people in the home are supported to maintain healthy eating plans to help them manage their weight and well being. Where these are in place there Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 15 must be clear evidence of the person’s involvement in the decision and the advice of a dietician or GP. People’s needs and preferences with regard to their personal care are outlined in the care plan. Safe moving and handling plans are in place for people with mobility difficulties and equipment to support them is available. A new parker bath has been recently installed to assist people with mobility difficulties. A screen is in place in the bathroom to allow staff to give people privacy in the bath whilst still ensuring their safety. Where people are able to manage their own personal care this has been recorded and risk assessments completed. Those spoken with said they were getting the support they need and that staff respect their privacy. Some people manage their own medication. Where people choose this option an assessment of their ability to do so safely is completed. They are then supported through a stage-by-stage process to manage their medication independently and safely. Trained and competent staff administer medication for other people in the home. It is recommended that the Manager hold a list of staff signatures and initials to cross-reference with important records in the home such as medication sheets. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People know how to make a complaint and know they will be taken seriously. They are safeguarded from harm and abuse. EVIDENCE: There is a complaints procedure for the service. This has been published in picture format for people in the home and displayed by the payphone in the home. Feedback from people in the home evidenced that they understand how to make a complaint. Examples were seen throughout the visit of people openly approaching staff and the Manager with questions, concerns or suggestions. This evidenced and open atmosphere where people feel they can talk to the staff. The complaints log shows that any complaints have been responded to quickly and effectively. There are other opportunities for people to raise any concerns including the monthly house meeting and meetings with Keyworkers. All staff have a criminal record check before they are allowed to work in the home. This includes a check against the Protection Of Vulnerable Adults (POVA) register. Staff have had training in supporting people to manage any challenging behaviour to safeguard all people living in the home. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 17 The Manager carries out weekly audits of any person’s money that is held by the home for safekeeping. Clear records are kept, but people’s finances could be further safeguarded by keeping receipts for any transactions made. The Manager of the home is a trainer in Safeguarding Adults. All staff have undertaken training in this area. The Safeguarding Adults policy has recently been reviewed to include a flow chart for staff to follow to ensure that any allegations are reported quickly and to the correct authority. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 27, 28 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The environment is safe, generally comfortable and meets the needs of the people in the home. They have access to sufficient bathroom facilities and communal areas. Some areas of the home require attention to ensure the home remains clean and free from risk of infection. EVIDENCE: Each person has a single bedroom and access to sufficient bathroom facilities. There is a new assisted bath on the ground floor for people with mobility difficulties. The shower room on the first floor does not have a sink and people in the bedrooms nearby stated that it would be useful to have one. The range of bathrooms meet the needs of the people in the home. People have access to a large lounge, large dining room and a games room. There is also a separate quiet lounge but this is currently used for office Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 19 storage. It is recommended that this be made more comfortable for people to use so that they can have the option of using it when they receive visitors. The carpet in the downstairs hallways is deeply stained despite regular cleaning and this now requires a professional deep clean or replacement. The rest of the house is kept clean and hygienic by a team of cleaners. People living in the home are supported to clean their rooms each week and a deep clean of all areas of the home is completed monthly. The radiators in the bathroom and shower rooms have become rusty and may present a cross infection risk. All communal areas of the home have been redecorated since the last inspection. A new Occupational Therapist has been recruited to the site and will be carrying out an assessment of the home to ensure the environment meets the needs of the changing service user group. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home are safeguarded by robust recruitment procedures for new staff. They are supported by trained, competent and qualified staff. EVIDENCE: Staff are recruited following robust company procedures. Staff records were sampled and evidenced that all required checks are made before a person is offered employment in the care home. When staff start work in the service they undertake an induction into the home which includes a period of shadowing senior staff. They are also required to complete the ‘skills for care’ induction. Most staff have gone on to do their NVQ award. New staff that have not yet started the NVQ are scheduled to do so after completion of their induction. As part of their induction staff complete training in Equality and Diversity. There is a comprehensive training package for staff. This includes all the training courses considered essential for safe working in the home, plus other Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 21 courses that support staff to meet the individual needs of the people living there. As the needs of the group of people using the service change the Manager plans to review the training courses that staff are required to complete. It is recommended that the Manager have a copy of the course content for each training course to provide evidence of the knowledge and skills that staff should be gaining from the courses. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People in the home benefit from a competent Manager and will further benefit from the Manager successfully becoming registered. The views of the people that use the service are obtained and used to shape the service. The service is run in a manner that ensures the well being and safety of the people that use it. EVIDENCE: The Manager of the home has been recently employed into the permanent post and is in the process of applying for registration with CSCI. The Manager is Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 23 completing the NVQ 4 in care and plans to complete the Registered Managers Award. The deputy Manager holds the NVQ 4 award in care. There is a strategic 5 year plan for the service that has been discussed with both staff and people living in the home. Two of the people that use the service are included on the management committee for the site. A new Quality assurance system has been introduced since the last inspection. This includes monthly quality audits of various parts of the service. People are asked their views of the service at the monthly house meetings and through representation on the committee. The Manager gave examples of changes that had been made in response to requests or comments by people in the home. Health and safety issues are monitored by the staff and Manager. Risk assessments are in place for individual risks, but also general risks in the environmental. Staff have completed training in health and safety, food hygiene and infection control. The new food hygiene ‘safer business’ pack has been implemented following recommendation from the Environmental Health Agency. Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 4 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 2 3 X LIFESTYLES Standard No Score 11 3 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 3 X X 3 X Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 25 No 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 YA7 Regulation 17(1)(a) schedule 3 (q) Requirement The registered person must ensure that a record is kept of any limitations agreed with the service user as to their freedom of choice. Where restrictions are made these must be evidenced that they are in the best interests of the individual. This must include a record of how any decisions were made and who was involved in the decision. The registered person must ensure that the stained carpets in the hallways are properly cleaned or replaced. The registered person must ensure that the radiators in the bathroom and shower rooms are repaired to reduce the risk of cross infection in the home. Timescale for action 30/11/07 2 YA24 23(2)(d) 31/01/08 3 YA30 23(2)(d) 30/11/07 Hampshire House & Redsteps DS0000022975.V337319.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. 1 2 Refer to Standard YA7 YA8 Good Practice Recommendations It is recommended that all staff undertake training in Person centred planning. It is recommended that more service users be consulted properly through the house meetings on matters that affect them such as allocation of Keyworkers. It is recommended that opportunities for community activities for service users be further explored. It is recommended that people be supported to make an informed decision about any proposed weight loss plan and their consent be sought and recorded where possible. It is recommended that the Manager hold a list of all staff signatures as a reference document for signed records of medication. It is recommended that receipts be obtained for all transactions made for service users money that is held by the home. It is recommended that people in the home be consulted as to whether they require a sink in the upstairs shower room. It is recommended that the quiet room be made more comfortable for service users to use. It is recommended that the Manager have access to the course content for all staff training courses so that he is aware of the skills and knowledge staff are being provided with. 3 4 YA13 YA19 5 YA20 6 YA23 7 YA27 8 9 YA28 YA35 Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hampshire House & Redsteps DS0000022975.V337319.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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