CARE HOME ADULTS 18-65
Huish House Huish Episcopi Langport Somerset TA10 9QP Lead Inspector
Pippa Greed Unannounced Inspection 19th December 2006 09:10 Huish House DS0000039967.V319729.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 Huish House DS0000039967.V319729.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. Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Huish House Address Huish Episcopi Langport Somerset TA10 9QP 01458 250247 01458 259384 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) Milbury Care/ Voyage South Care Home 12 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Registered for 12 persons in categories LD and PD Date of last inspection 15th March 2006 Brief Description of the Service: Huish House provides a home for up to 12 adults between the ages of 18 and 65 who have a learning disability and associated needs including autism, sensory impairments, physical disability and epilepsy. Huish House is owned by Milbury Voyage, a company that provides residential services for people with a learning and associated physical disability in Somerset. The home provides an attractive and spacious environment in a semi rural location near Langport. The individual’s rooms are decorated in individual styles and furnished in an eclectic manner. There is a range of communal spaces complemented by activity rooms Adaptations are provided to meet the individual and collective needs of service users. The acting manager Lisa Richards is currently applying to register with CSCI. The current scale of charges is £1,102.57 to 1,839.25. Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced Key inspection was conducted over one day (8hrs) by CSCI Regulation Inspector Pippa Greed. On the day of the inspection, six support workers, one deputy and the manager were on duty. There were two waking night staff and one sleep in duty rostered for that evening. The acting home manager and deputy manager were available to assist the inspector during the unannounced visit. On the day of the inspection twelve service users were at home initially. Two service users left around mid morning to attend a health appointment and go out for lunch. Five service users accessed reflexology sessions during the morning and one service user went out for a drive and Christmas shopping during the afternoon. The atmosphere was relaxed and informal. Staff were seen to work in a caring manner with the service users. The inspector viewed all communal areas and eleven service users rooms. The inspector met with and engaged with six service users. The inspector sat with and had lunch with the service users and staff and also observed daily routines within the home. The inspector met with two staff members to discuss their induction, supervision and training provision. The staff commented that they felt supported by the acting manager. A selection of records was examined. These included three service users care plan and three staff recruitment files. CSCI sent out feedback cards for three service users, five staff, three relatives, three social workers and one General Practitioner. Three care staff comment cards confirmed that they understood organisational policy on Adult Protection. One staff wrote that they would benefit from Non-Violent Crisis Intervention (NVCI) training and another staff wrote that they enjoy working at Huish House. One comment card was received from parent whose comment was overall positive but expressed concern about recent staffing level in the home. The manager is planning to do further recruitment in the New Year. Two comment cards were received from Social Workers. One confirmed that they felt satisfied with the overall care within the home and another wrote about identified concerns with a service user’s care plan needs. This is detailed in the report and is currently being addressed. One GP comment card has been received and this confirmed that the service provides good care. The GP wrote ‘Huish House is an extremely well run home
Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 6 for young patients with severe learning difficulties. It is a pleasure and a privilege to work with the staff and patients.’ The inspector would like to thank the service users, staff, and manager for their time and hospitality shown to the inspector during her visit. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: What has improved since the last inspection? What they could do better:
Three requirements and eight recommendations have been raised at this inspection. The organisation needs to ensure that a copy of the service users contract is available in the service users file. This requirement has also been carried forward. The manager must ensure that the service user’s care plans are kept under review. Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 7 The manager must also ensure that staff are provided with mandatory training refresher. 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. Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users and their families are provided with relevant information regarding the home. Social and health assessments are completed to ensure that the home is able to meet service users’ needs. EVIDENCE: The home has a Statement of Purpose that provides details of the services and facilities provided at Huish House. The Statement of Purpose is presently being updated to reflect the changes within the organisation. The service users contract is stored at head office. It is good practice to include a copy in the service user’s care plan. The Statement of Purpose outline criteria for admission. Initial referrals may come from either a parent/ carer or from a social worker. A written profile and detailed assessment is obtained from the social worker, which would allow for Voyage’s Operations Manager to assess the suitability for placement. There is no set timescale as each case is judged on the service user’s needs. Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 10 The Service Users Guide is provided in a simple easy to understand format. It is written using Picture Bank images for ease of understanding. The Service User’s Guide covers the following: What Huish House can offer you, Your rights, How much it costs?, What to do if you don’t like something?, What other service users want to happen at Huish House and Where to find copy of CSCI report and contract. The Service Users Guide is stored in individual care plans, which is good practice. Pre-admission assessments are kept in a separate file. Two service users came to the home straight from school. The home provided overnight stays at the home to enable the service user and family to ‘test drive’ the home. Staff also visited the service user’s family home and school in order to get to know the service user well and prepare for smooth transition. The care plans sampled evidenced detailed assessment of needs provided by funding authority. There are no vacancies at present. Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is currently updating care plans for each service user. Service users are encouraged to exercise choice and participate in all aspects of life within the home. Service users risk assessments are in need of updating in order to ensure service users are supported in taking risks. Records relating to service users are stored securely and appropriately maintained. EVIDENCE: The inspector sampled three service users care plan files. One file did not contain a ‘care plan’ and another required updating. The care plan constitutes service users routines and guidelines. The manager is currently updating all
Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 12 service users care plans. These would need to be made priority in order to ensure that service users social and health care needs are maintained. Risk assessments will need reviewing in order to reflect changing needs and ensure service users are supported in taking risks safely. One comment card was received from a social worker. The social worker wrote about issues relating to care planning. Specific dietary needs were identified as a concern. A review meeting was held and the issues have been addressed. The social worker stated that the manager has now implemented measures to address one individual dietary and health care needs. Three care plans files were examined in detail. These files included a photograph of the service user, and provided information regarding service users needs. This included general health (dental, optical, chiropody), medication, diet, self-help skills, daily living skills, activities, communication, social and behaviour. The service user’s guide stored in the care plan file includes a complaint procedure and Protection of Vulnerable Adult guidance. This is written in a simple and clear format with pictures. The monthly summaries are completed by key support worker and were completed on a regular basis. Service users were seen to move around the communal parts of the home freely and choose their company. Service users are enabled to use their own bedrooms in order to engage in their choice of pastime. Some bedrooms are equipped with personal effects such as sensory lights, soft balls, tactile toys, plasma ball, games, television, DVD/ video and music system. Staff will support service users in managing their finances where required. Financial records were examined for two service users. One staff signature supported all entry. The entries were correct for expenditures and tallied with the balance. It is recommended that the manager consider implementing a more detailed finance record to include two staff signatures on all transactions. Currently, no service users have the support of an independent advocacy service. All records relating to service users are stored securely and kept confidential. Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home offers service users opportunities to engage with peers, access appropriate leisure activities, and exercise choice. Service users rights and responsibilities are respected. Service users are offered a choice of menu, and were seen to enjoy the meals provided. EVIDENCE: Staff from the home support service users continued access to social and leisure resources. On the day of the inspection, twelve service users were at home. Five service users attended reflexology session during the morning. One service user was supported with an appointment to see the GP and two service users went out
Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 14 for lunch with staff. One service user went for a drive and Christmas shopping during the afternoon. The previous evening, six service users enjoyed an evening out to a Christmas disco and buffet. Activities provided by the home and in the wider community includes the following: bus trips and meals out in the community, swimming, cookery at local college, reflexology, horse riding, massage & aromatherapy, beauty therapy at local college, art therapy, and trampolining. The service users who live at the home have complex needs and require support and assistance in all aspects of daily living. The inspector observed how support was offered during the day. The inspector spent some time sitting in the lounge observing interaction by staff with service users. There were positive interactions with service users. However, it is recommended that more consideration be given to ensure staff engage with all service users as fully as possible. Further training in specialised communication skills could be provided in this area. The home provides a sensory room, which includes ball pit, beanbags, disco ball, ceiling star lights, rope light, music system, light projector and water bubble display. This room is also used for reflexology sessions. The home also organised a short holiday to Croyde for all service users earlier in the year. The home strives to maintain regular contact with service users family members. Care plans provide details of service users personal and family relationships. There are many photographs of service users and their families in individual bedrooms. Six service users are supported with monthly home visits where they spend the day or weekend with their family. The home has a menu that reflects the likes and dislikes of the service users. The menu offered for the week provided a balanced and nutritious diet. The dining room board depicts the meal for the day with simple symbols and photographs. On the day of the inspection, lunchtime was relaxed and unhurried. The inspector sat with and dined with the service users whilst observing the lunchtime routine. Service users were seen to be enjoying their meals and staff offered care and support in a kind manner. Staff spoken with appeared aware of service user’s specific dietary needs. Huish House DS0000039967.V319729.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are provided with appropriate assistance to meet their personal care needs. The home supports service users in accessing healthcare services. The home has aids and adaptations to assist the service users in their personal support. The home promotes service user’s privacy and dignity. Medication Administration Records are managed safely. EVIDENCE: Service users are provided with support to undertake personal care tasks as required. Many service users have complex health care needs. Staff supports service users in accessing healthcare services and ensure that specialist advice is sought as necessary. The care plans that were sampled contained documentation of the visits made to health care professionals. These included visits to the GP, dentist, chiropodist, and optician. Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 16 A record is maintained in care and support plans of healthcare appointments and outcomes. The home supported one service user through a period of illness. The home received good medical support and through continued intervention, an appropriate course of treatment was identified. The current treatment appears to have benefited the service user and improved their quality of life & wellbeing. The home has aids and adaptations to assist the service users in their personal support. Service users have the use of technical aids and equipment where needed. The health and safety checks for these equipments are maintained regularly. The bedrooms have en-suite facilities so this promotes service users’ dignity when supported with personal care. No current service users are able to self-medicate. The inspector sampled the Medication Administration Record and storage of medication. This was considered well maintained. The Medication Administration Record file had medical footnote and photograph ID of each service user. The home carries out audits on the storage and administration of medications every month as good practice. Some minor gaps were seen on the Medication Administration Record. The medication storage area was clean and tidy. It is recommended as good practice that two staff signatures support all hand transcribed entries. It is also recommended that variable dosage be recorded. The home has a policy relating to ageing and death. The care plans does not contain details relating to standard 21. Huish House DS0000039967.V319729.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a clear Adult Protection policy, which is accessible. Staff are clear on correct reporting procedure. The home has systems in place to protect the service users from abuse. EVIDENCE: The home has appropriate policies relating to the Protection of Vulnerable Adults, Whistle Blowing, Complaints policy, and Grievance policy. Three staff comment cards were received. The inspector also spoke with two staff members. They confirmed they knew where Protection of Vulnerable Adults information is kept. They also stated that they understood how to report any concerns about poor care or allegations of abuse. POVA training has been offered to new staff members through induction training or Learning Disability Awards Framework (LDAF). However, it is recommended that all staff receive POVA training update as good practice. The manager informed the inspector that no complaints had been made since the last inspection. Similarly none has been reported directly to CSCI. Whilst the home has a complaint log in place, the complaints policy should make clear to complainants that they are able to contact the Commission for Social Care Inspection at any stage of a complaint.
Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 18 The inspector sampled the company’s Whistle Blowing policy. Section 4.4 could be further improved to demonstrate to the Whistleblower that they can raise concerns outside the organisations if they wished. The Public Interest Disclosure Act 1998 provides clear ‘good practice’ guidance. Three staff recruitment files were sampled and these contained information required by Schedule 2, Care Homes Regulations 2001. Criminal Records Bureau (CRB) checks are in place for all staff. POVA 1st checks have been carried out on newly recruited staff. The manager has recently been reinforcing staff’s skills and knowledge in policy and procedure and ensuring that staff knows where to access this info. The Complaint and Whistle Blowing policy are displayed on wall in staff office including a flow chart. Huish House DS0000039967.V319729.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has been decorated and furnished to a high standard. The home has sufficient communal areas and bathrooms to meet service users’ needs. The home was found to have a good standard of cleanliness. EVIDENCE: Huish House is a large imposing manor house situated in a semi-rural setting on the outskirt of Langport, affording views of the countryside to the rear of the property. The home is surrounded by a large garden, which includes a patio area with a pond. The home has twelve single rooms, five of which are on the ground floor and seven on the first floor. Three bedrooms are accessible for wheelchair users. All rooms have en-suite facilities. Bedrooms are adapted and personalised according to individual needs and tastes. Social areas include a large lounge Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 20 and balcony area, two dining rooms, sensory room, training kitchen and main kitchen. Service user rooms are single occupancy. All rooms have an en-suite bathroom. Service users rooms have been decorated to a good standard and are personalised with their own belongings, double bed, television and DVD player, sensory lighting and decorative posters. The Inspector saw records of daily fridge and freezer temperatures. These were found to be within safe range. Food probe records were seen and were maintained within appropriate range. Huish House DS0000039967.V319729.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff are experienced and provide a good standard of care. Staffing level is adequate in order to meet service users’ needs. Mandatory training updates for the staff is required. Staff receive appropriate support and supervision. EVIDENCE: Duty rotas are maintained appropriately. On the day of the inspection, the home was staffed with six staff (including the manager) during the day, three staff during the evening, two waking staff and one sleep in duty at night. It was reported that three new staff have joined the service since the last key inspection. Staff spoken with confirmed that they had received appropriate support and supervision. Staff file evidenced that frequency of supervision varied. Staff Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 22 meeting are being provided regularly. It is recommended that staff are provided with formal one to one supervision at least six times a year. Observation of care provided throughout the inspection process showed that the staff team are caring and demonstrated rapport with the service users. However, it is recommended that more consideration is given to ensure staff engage with all service users as fully as possible. This will improve with increased staffing as there are currently three staff vacancies being advertised. Three staff recruitment files were examined which included evidence of enhanced CRB disclosure being obtained. The files contained documentation required by Schedule 2 of Care Homes Regulation 2001. The induction workbook provided a comprehensive guidance on induction training which included Policy & Procedure, Learning Disability awareness, Manual Handling, Infection Control, Risk Assessments, Control of Substances Hazardous to Health (COSHH), Accident & Incident reporting, Food Hygiene, Fire Safety, Health & Safety, Abuse awareness, Stress management and support worker’s role. The staff training matrix was viewed and there is evidence that the staff team are undergoing a programme of training updates throughout the year. Training topics included Induction, Food Hygiene, Learning Disability Awards Framework (LDAF), First Aid, Health & Safety, Minibus, Rectal Diazepam, and Manual Handling. The training matrix evidenced that some staff mandatory training are in need of updating. It is required that staff are provided with mandatory training refresher. The Pre-Inspection Questionnaire provided stated that four staff from nineteen have completed NVQ 2 or above. It is recommended that all staff are provided with Protection of Vulnerable Adult training, medication training and further increase the level of NVQ trained staff. Huish House DS0000039967.V319729.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is managed well. There is a relaxed and open atmosphere within the home. Appropriate actions have been taken to promote the health and safety of staff and service users. EVIDENCE: The acting manager is Lisa Richards. Lisa has worked in care for thirteen years. She started her career with the company as a support worker and has gained experience of all abilities and needs. Lisa has previously worked as registered manager for a fourteen bed unit. This includes extensive work with young vulnerable adults. Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 24 Lisa has attained NVQ 3. It is recommended that she undertake NVQ level 4 in management and/ or the Registered Manager’s Award (RMA). Lisa has worked proactively at Huish since coming into post to address identified issues such as improving care plans, staff supervision and appraisals, monitoring staffs performance and boosting team morale. Staff spoken with confirmed that they feel happy working at Huish House. Lisa is supported by one deputy manager and two senior support workers. Staff spoken with confirmed that the manager was approachable and that they would be able to raise any concerns. The home has appropriate policies and procedures in place to safeguard vulnerable service users. All records relating to service users are stored securely in accordance with the Data Protection Act 1998. The home has a current Employers Liability insurance. The home operates a comprehensive system of health and safety audits. Fire safety records were examined. Fire equipment had been serviced and tested as required. The portable appliances, landlord gas safety certificates, water temperature and hoist checks have been appropriately maintained. It is recommended that Legionella review be carried out annually. Accidents have been recorded and an analysis completed on a monthly basis. The monthly analysis are complied by the manager and sent to Voyage Head Office for further audit. This is considered as good practice. Huish House DS0000039967.V319729.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 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 4 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 3 3 3 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 3 3 3 3 3 3 Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 26 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 YA5 Regulation 5 (c) Requirement The manager must ensure that a copy of the service users contract held on the individuals file. Carried forward from the last inspection. The manager must ensure that the service user’s care plans are kept under review. This includes service user’s risk assessments. The manager must ensure that staff are provided with mandatory training refresher. Timescale for action 01/03/07 2. YA6 15 (2b) 01/03/07 3. YA35 13 (4) 01/03/07 Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 27 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 Good Practice Recommendations It is recommended that the manager consider implementing a more detailed finance record to include two staff signatures on all transactions. It is recommended that more consideration be given to ensure staff engage with all service users as fully as possible. Further training in specialised communication skills could be provided in this area. It is recommended as good practice that two staff signatures support all hand transcribed entries. It is also recommended that variable dosage be recorded. The organisation may wish to consider its policy with regards to vulnerable adults so that it empowers the individual to contact either of the statutory agencies with their concerns. It is recommended that all staff are provided with Protection of Vulnerable Adult training, medication training and further increase the level of NVQ trained staff. It is recommended that staff are provided with formal one to one supervision at least six times a year. It is recommended that the manager undertake NVQ level 4 in management and/or the Registered Manager’s Award (RMA). It is recommended that Legionella review be carried out annually. YA11 3. 4. YA20 YA23 5. 6. 7. 8. YA35 YA36 YA37 YA42 Huish House DS0000039967.V319729.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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
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