Inspection on 13/06/07 for Hermitage Lane (4)

This inspection was carried out on 13th June 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hermitage Lane (4) 19/07/06

Hermitage Lane (4) 12/10/05

Hermitage Lane (4) 28/04/05

Hermitage Lane (4) 14/10/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hermitage Lane (4) Hermitage Lane Upper Stratton Swindon Wiltshire SN2 6QS Lead Inspector Pauline Lintern Key Unannounced Inspection 13th June 2007 10:00 Hermitage Lane (4) DS0000061405.V332952.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 Hermitage Lane (4) DS0000061405.V332952.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. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hermitage Lane (4) Address Hermitage Lane Upper Stratton Swindon Wiltshire SN2 6QS 01793 727790 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 Milbury Care Services Limited Vacant Care Home 6 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than one service user aged over 65 years named in the application dated October 2006 may be accommodated. 19th July 2006 Date of last inspection Brief Description of the Service: 4 Hermitage Lane is one of number of homes owned and managed by Millbury Care Services. The property is a large detached house located down a quiet lane and within easy reach of local amenities, public transport and Swindon Centre. The home provides accommodation for six service users with learning disabilities with the philosophy of care underpinned by John O’Brien’s five accomplishments. The emphasis of care is to promote independence and support service users enjoyment in experiencing the wider community. The accommodation provides single bedroom en suite facilities for all service users that exceed the National Minimum Standards for communal and living space. Staffing arrangements ensures there is a minimum of three staff on duty at all times Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took five and three quarter hours to complete. The manager Jessica Bailey was present throughout the visit. Ms Bailey has not yet registered as manager with the commission. All six service users were at home on the day of the inspection, although they were out at various times to swimming or for walks. The inspector met all service users, although was only able to gain the views of one person. Two staff met in private with the inspector. Survey forms were sent out to relatives, care managers and health care professionals to seek their views. The inspection involved a tour of the premises, examination of two care plans and the associated risk assessments for the two individuals. Health and safety records, medication practices, staff recruitment and activities were all sampled. The fees charged at 4 Hermitage lane range from £1165 - £1470 per week. What the service does well: What has improved since the last inspection? The last inspection identified seven requirements and these have all now been met. Medication is now recorded when it is received into the home. The carpet in the hallway has now been replaced, however it did not include replacing the stair carpet, which now remains unsightly and stained and detracts from the nice carpet in the hallway. Staff members are now receiving regular formal supervision, which is documented. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 6 The Commission have received a copy of the outcome of the last quality review. Morale within the staff team appears to have improved. 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. Hermitage Lane (4) DS0000061405.V332952.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 Hermitage Lane (4) DS0000061405.V332952.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): 1 and 2 Quality in this outcome area is good. Service users are provided with information about the home. Potential service users have their needs fully assessed prior to moving into the service. This judgement has been made using available evidence including a visit to this service. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 9 EVIDENCE: There have been no new admissions to the home since the last inspection. Each service user had an assessment of their needs to ensure the home can provide a service and meet the identified needs. Assessments sampled showed that consideration had been given to physical and emotional needs, mobility, communication, diet, accommodation, health, likes and dislikes and activities. Related risks are measured and strategies identified to minimise the risk are put in place. Each service user is provided with a service user guide, which is in a pictorial format and contains a section on how to raise a concern or make a complaint. There is a updated statement of purpose, which provides the reader with relevant information about the service. The home has a key worker system in place, which provides a consistent approach and helps to build relationships. One service user confirmed the name of their key worker and reported that they “like him”. One new staff member explained that they had been given the opportunity to get to know the service users and read all the care plans before they worked alone with service users. They confirmed that they had been provided with sufficient information to allow them to carry out the tasks expected of them. Hermitage Lane (4) DS0000061405.V332952.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): 6, 7 and 9 Quality in this outcome area is adequate. Each service user has a care plan, which is kept under review and reflects the service users assessed needs. Service users could be further empowered to make decisions by promoting person centred planning. Risk assessments are in place and have recently been reviewed, however the restriction of access to the kitchen area would benefit from being reviewed for each individual. This judgement has been made using available evidence including a visit to this service. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 11 EVIDENCE: As part of the inspection process two care plans were examined. Plans contained clear and concise information, which is also in a pictorial format. The plans reflect the service users assessed health and care needs and identify how they will be met. Each plan explains to the reader the communication needs for the service user, supported with a communication passport to ensure that staff have a good understanding of their method of communication. As one service user uses some signs as their communication method it would be good practice for staff to learn basic sign language, which they could then develop with the service user. The manager confirmed that arrangements have been made for a staff member from another service to come to the home and provide staff with some guidance in sign language. Staff members explained how they offer choices to individuals with regard to clothes or choices of drinks. This is an area that could be further developed and was discussed with the manager. The manager explained that she would like to see service users having more input into the planning of meals. She confirmed that she had recently discussed a system that may be used for choosing menus with the operations manager and was hopeful that this may be adopted. The manager reported that at the time of the inspection no service user has an advocate although the manager felt it might be an area to explore for one service user who has no family. Risk assessments have recently been reviewed and staff are asked to sign and confirm that they have read and understood the contents. It was suggested that the manager review the individual risk assessments in relation to restrictions on accessing the kitchen area as this may be resulting in preventing one service user being able to maintain their independence and domestic skills. At a recent review meeting it was identified that an occupational therapist assessment may be beneficial. The manager confirmed that she would chase this up. Hermitage Lane (4) DS0000061405.V332952.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): 12, 13, 15,16 and 17 Quality in this outcome area is adequate. Generally access to activities has improved for service users, however this is an area where there still remains scope for further improvement and opportunities. Service users are part of the local community. Appropriate relationships with families and friends are encouraged and supported by the staff team. Some staff members may benefit from further training in ‘valuing people’ to ensure they are able to promote respect, choice and independence. The home provides service users with a well-balanced and varied menu although more service user participation in meal choice would be good practice. This judgement has been made using available evidence including a visit to this service. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 13 EVIDENCE: During the inspection service users were observed going into the local community for walks and shopping. The manager explained that the number of activities offered to the service users has improved and service users now attend bowling, music alive, Gateway club, the gym, swimming, shopping, walks and trips to the pub. One service user reported that he enjoyed going out in the local park on his bike with staff support, an activity that has been risk assessed. At the time of the inspection six service users were at home and although a couple ventured out for a walk and one was going swimming there was a sense that service users were not generally participating in activities around the home. Video’s/music were continually being played in the lounge with fairly vocal staff input, which may not have been to everyone’s liking. The general feeling was one of a noisy environment and that there was no particular structure for the service users. This was discussed in feedback with the manager who agreed that service users would benefit from a more structured day and that this was an area she hopes to develop. The home’s statement of purpose states that ‘4 Hermitage Lane is a place that will support an individual to develop new skills both within the service and in the community’. However, although the staff team are obviously caring and well meaning this is an area where improvements could be made. It was also noted that one carer was using ‘over friendly’ terminology when interacting with the service users, which again was discussed with the manager and she confirmed will be addressed. The manager discussed holidays for the service users and confirmed that they are in the process of gathering information on various venues. One service user reported they are looking forward to going to Weymouth in July with their relatives. One person’s case file showed that they enjoy going to farms, parks and zoos and there were photographs of past visits. One service user explained that they enjoy going to the railway museum and at their review they had expressed a wish to go to the local speedway. The manager confirmed that this had not yet been arranged. One service user has a pet rabbit at the home and explained that they took responsibility for cleaning it out. Staff members confirmed that most of the service users have input from their families and one service user goes home on alternative weekends. The service user confirmed that they are able to telephone their mother, with staff support when he wishes. Relative’s surveys returned to us comment on the activities offered by the service as follows; Yes I think they are taken out frequently. I believe the care service support people to live the life they choose. They give to my son, all that he needs and likes to do. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 14 Each bedroom has a key hung above the door, although the manager reported that no one chooses to lock them unless on occasions when the service user is away, then staff lock the door for them to prevent anyone else from entering. One staff member confirmed that when mail arrives it is given to the service user and staff will support them to open and read the contents. Staff members were observed interacting with service users at the time of the inspection, however feedback from surveys suggests that this is not always the case when the manager is not present. It was noted that some entries in the daily diaries used judgemental language contrary to the ethos of the home; this was discussed with the manager at the end of the inspection. The manager explained that at the present time the home run a ‘rolling’ fiveweek menu. It would appear that service users have little input into the choosing of the menu, however as mentioned previously in this report the manger is already addressing this but looking at alternative methods of menu planning. Having said that the menus are varied and healthy options are available. One service user reported that they enjoy the food at the home. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. Personal support is delivered in a way service users prefer. The home ensures that service users physical and emotional needs are met. There are safe systems for administration of medication in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans sampled enable staff to provide support to service users in a way they prefer. Service users identify ‘how I want staff to assist me and how I don’t want staff to treat me’. There are clear guidelines on morning and evening routines and when verbal prompts may be required. There is evidence to show that behavioural management is in place and all incidents are documented. The staff team receive guidance and support when needed from the local consultant psychiatrist. One file sampled states that staff should ‘not assume behaviours are just for attention, they need to check Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 16 if the person is unwell’, which show that staff members have a good understanding of the person’s needs and requirements. The home has a policy not to use restraint, instead all staff receive practical and awareness training in non-violent crisis intervention (NVCI) and attend refresher training to maintain their skills. Staff members support service users to appointments with healthcare professionals such as doctors, podietrists, opticians and dentists. All appointments are recorded in individual files. Feedback from health professionals was positive, for example; “We have two patients there, we do not see a lot of them, which I think is a sign of good quality care in that the staff have taken these patients situations in hand and are using plenty of initiative in their care. When we have seen these two patients there has obviously been a good rapport with the staff and they show every sign of being well cared for. I last visited there in Oct 04 when I found the building in good condition and a good relationship between clients and the staff”. “No concerns regarding this service. Did have previous concerns regarding residents getting out, this is no longer a problem and has improved”. Relatives were asked; ‘Are you kept up to date with important issues affecting your relative/friend (for example if they have been admitted to hospital or had an accident?) Three people responded ‘always’ and one said ‘usually’. They were also asked; ‘Does the care home or agency give the support or care to your relative /friend that you expect or agreed? Again three people confirmed ‘always’ and one said ‘usually’. Staff members confirmed that they do not administer medication until they have satisfactorily undertaken an assessment of their competency. One new member of staff confirmed that she does not administer medication yet as she has not completed her assessment. One staff member confirmed that all staff have refresher training for the administration of medication. This takes place every three months. Medication records were sampled as part of the inspection process and no gaps were found in entries. Medication received into the home is now signed in by two members of staff and recorded. Each medication record has a photograph of the service user to clearly identify them. All staff attend ‘Boots’ training in the safe handling of medication. Staff sign to say that they have read and understand the policy on ‘as required’ (PRN) medication. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. Service users are provided with a copy of the complaints procedure in a pictorial format. Service users are protected from abuse where possible, however the manager should ensure that all new staff have a basic knowledge of the local protocols on the commencement of their employment. This judgement has been made using available evidence including a visit to this service. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 18 EVIDENCE: There is a copy of the complaints procedure on display in the hallway of the home. Each service user has a copy of the complaints procedure in a pictorial format in their service user guide. Feedback from survey forms suggests that most relatives know the procedure for making a complaint or raising a concern. One person did report that they did not know the procedure and this was discussed with the manager who confirmed that she would re-send a copy to everyone. Some of the comments received regarding raising concerns were as follows; I cant imagine having the need to complain. The care service responded appropriately by writing twice to reassure me, that the problem will be dealt with of which is done accordingly. I once made a complaint of which I was reassured that whatever made me complain will never happen again. The home’s complaints log shows that there have been no recorded complaints within the last twelve months. The Commission has received one anonymous concern relating to the care provided at the home and also some areas of concern relating to independence and choice raised by other agencies. These areas have been explored as part of the inspection process. The inspection has identified one requirement and one recommendation relating to the need to improve opportunities for maintaining independence and offering choice to service users. Discussion with staff confirmed that they have a good awareness of the local protocols for reporting suspected abuse. However, one new staff member appeared unsure of the procedure, as they were new to care and had not yet received the training in this area. Although there are arrangements made for her to attend this training in the next four weeks it would be good practice to ensure that new staff are given basic direction and guidance as soon as they commence work to safeguard the service users. A copy of ‘No Secrets’ was available at the home. The system for looking after service user’s money was checked and found to be in good order. Two money tins and records were examined and both balanced. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. The home provides service users with a homely, comfortable and safe environment. The home was clean and hygienic at the time of the inspection. This judgement has been made using available evidence including a visit to this service. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 20 EVIDENCE: A tour of the building demonstrates that it is providing a physical environment that is appropriate to the needs of the people who reside there. The home is generally well maintained and most furniture and fittings were of a satisfactory standard. One service showed the inspector their bedroom and reported that they ‘liked the room’. Feedback from surveys was generally positive regarding the cleanliness of the home. Each bedroom has been personalised and each have personal photographs and belongings around them. Each room has en-suite facilities, which were all found to be clean and odour free. Following a requirement set at the last inspection the carpet in the hallway has now been replaced, however this replacement did not include the staircase, which slightly spoils the appearance of the new carpet as it meets badly stained and worn carpet at the stairs and detracts form a well maintained home. All communal areas were found to be clean and tidy. There is a nice garden, which was also well maintained with plenty of tables and chairs to accommodate the service users. There is plenty of space for service users to be alone if they wish such as the conservatory and two lounge areas. There is a separate room that houses the washer and dryer. It was noted that there were plenty of gloves available for staff members to use. The manager confirmed that aprons are also aprons provided, however these were not seen. Staff members confirmed that they have attended training in infection control and there is evidence that it is on the training programme for the year. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. Staff demonstrate overall competency and appear to be sufficient in numbers, properly recruited, inducted, and trained. Staff are now receiving regular formal supervision. This judgement has been made using available evidence including a visit to this service. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager reports that 8 of the staff team are qualified to National Vocational Qualification (NVQ) level 2 or above. There is a comprehensive training programme in place, which includes fire awareness, first aid, protection of vulnerable people, health and safety, person centred planning, principles of care, autism, epilepsy, safe handling of medication, non-violent crisis intervention, manual handling, infection control, basic food hygiene and communication. Prior to embarking on a NVQ, staff complete the Learning Disabilities Awareness Framework (LDAF) training, which provides them with a sound underpinning knowledge and also can be used as evidence for their NVQ. The new member of staff explained how she was inducted into the service and confirmed that at no time was she not supported or supervised. She explained that she used the first few days to familiarise herself with care plans, risk assessments and policies as well as getting to know the service users. One service user said that they liked all the staff but were a little unsure of new faces in the home. The home has a comprehensive induction programme, which covers all areas. Staff confirmed that they have been given a contract and a job description. There is evidence that each person has been recruited following the correct procedure. Each person has been checked with the Criminal Records Bureau (CRB) prior to appointment. Two references are sought and records show that the staff member’s identity has been checked. Each staff member has an individual training plan and training needs are discussed in supervisions. Supervision is an area that has improved since the last inspection. Staff confirmed that they now receive regular formal supervisions. Three records were sampled. Staff report that things at the home have now improved and they now feel supported. A positive feature of this service is that staff are recruited from a number of ethnic and social groups to reflect the local population. Staff members report that they attend regular team meetings. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 23 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 good. Generally the home is well run. Service users views are obtained where possible on the development of the home. The home is considered to be safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has not yet applied to be registered with the Commission. She commented that she has recently moved and needs to get details of her new doctor before she submits her application to us. Staff members confirm that there have been improvements at the home. Staff report that “Jessica is excellent, open and relaxed. She is supportive and has a good understanding of the service users needs”. The manager explained that she is due to attend a management course before commencing her Registered Managers Award (RMA) and her NVQ level4. It is evident that the manager has made some Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 24 positive changes and that she understands there are still some areas, which need to be developed further. Observation indicates that she has a good rapport with both the staff members and the service users. Staff report that she is approachable and supportive. The home is currently recruiting for a deputy manager and once this post is filled it should be helpful to the manager to be able to delegate tasks and share responsibility. Survey forms sent to relatives asks; How do you think the care home or agency can improve? And What do you feel the care home or agency does well? Comments received include: I dont think that there is any need for improvement, in my opinion the staff work really hard. I believe that the staff are dedicated to their work. They do not need to improve as they have already achieved, great improvement. Everything is well organised. More trained/skilled/caring staff that understand the service users and their needs. Some training in Makaton sign language may help. There are mechanisms in place to monitor quality assurance. Milbury complete an annual audit (copy sent to the Commission). Service users meetings take place monthly following the staff meeting. The manager explained that if a service user chooses not to attend the meeting, the staff team utilise this time by discussing the needs of the service users. Milbury in line with standard 26 of the National Minimum Standards completes monthly audits and these are made available for inspection. Records show that service users have been sent a pictorial questionnaire on 2/04/07 asking for their views on their bedrooms and if they are happy at the home. Health and safety appears to be managed well within the home. Staff members have overall responsibility for certain health and safety checks. The manager explained that the person who was responsible for the legionella checks has recently left so the latest check may not have been completed. All other checks have taken place on a regular basis including all the relevant fire system checks, hot water temperatures, and fridge/freezer temperatures. Food stored in the fridge is dated as to when it was opened and hot food is appropriately probed to ensure safe temperatures. All windows have restrictors and radiators are guarded to ensure the safety of service users. The home has a current Gas safety certificate dated 19/07/06 and all electrical appliances were tested on 29/07/06. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 25 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 3 3 X 4 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 26 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 YA9 Regulation 13(4)(b) Requirement The registered person must ensure that the restriction to the kitchen area is individually risk assessed for each service user. The registered person must explore new opportunities and activities for service users to participate in both internally and externally to enable them to develop and maintain their independence. Timescale for action 13/09/07 2. YA12 16(2)(n) 13/08/07 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. Refer to Standard YA22 YA16 YA32 YA23 Good Practice Recommendations The registered person must ensure that all families receive information on the homes complaints procedures. It is recommended that staff receive training in the correct use of terminology when addressing service users. It is recommended that staff are provided with some basic sign language skills. It is recommended that new staff are given basic DS0000061405.V332952.R01.S.doc Version 5.2 Page 27 Hermitage Lane (4) 5 6 7 YA16 YA35 YA7 instruction on local protocols for reporting suspected abuse when they commence their employment. It is recommended that staff do not make judgmental statements when completing service user’s daily diaries. The registered person should ensure staff receive equal opportunities training. It is recommended that service users are encouraged and supported to make more decisions regarding the way they choose to live their lives. For example menu planning. Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Hermitage Lane (4) DS0000061405.V332952.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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