Inspection on 19/09/05 for Inglenook House

This inspection was carried out on 19th September 2005.

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

Other inspections for this house

Inglenook House 04/09/07

Inglenook House 28/09/06

Inglenook House 07/03/06

Inglenook House 19/10/04

Inglenook House 04/05/04

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 MIXED CATEGORY MAJORITY ADULTS 18-65 Inglenook House 46 Lipson Road Lipson Plymouth Devon PL4 8RG Lead Inspector Wendy Baines Unannounced Inspection 19th September 2005 11:00 Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 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 Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 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 Older People and 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. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Inglenook House Address 46 Lipson Road Lipson Plymouth Devon PL4 8RG 01752 229448 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) Jan Limited Dawn Florence Bartlett Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (10), Physical disability (10) of places Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Learning disabled adults some of whom may have a physical disability Age 18yrs Date of last inspection 19/10/04 Brief Description of the Service: Inglenook House is a care home Registered to accommodate 10 Adults with a Learning Disability, some of whom may also have a Physical Disability. The Registered Provider is Jan Ltd, and the owners of the home are Mr & Mrs Nicholson who are also the owners of the property next door, which is a Registered care home. The range of needs catered for includes, adults with medium to high levels of dependency. The house is a large, mid-terraced property situated in the Lipson area of Plymouth and is close to the city centre and local shops and parks. Service users are accommodated in six single, and two double bedrooms. There is a large lounge, separate dining area, kitchen, laundry, and garden/patio area. There is level access to the rear of the property and a ramp that can be fitted to the front access to support service users requiring the use of a wheelchair. Service users are supported to partake in a range of daytime and leisure activities dependent on their assessed needs. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection was unannounced and took place on the 19th September 2005, between 10am and 3pm. The Registered Manager, Dawn Bartlett was not available, but the home- owner Mrs Amanda Nicholson was present throughout. A tour of the premises took place and records relating to service users, staff, and the running of the home were made available. The Inspector met and spoke with the service users and staff who were in the home during the inspection. The Registered Provider had completed a Pre-inspection questionnaire, and comment cards sent to CSCI included positive feedback from service users. What the service does well: What has improved since the last inspection? Since the last inspection the home has continued to support a service users requests to consider options for the future. The Registered Manager has liaised Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 6 with outside agencies regarding the changing healthcare needs of a service user. Staff have been provided with advice and guidelines and this has resulted in an improvement in the individuals health. Arrangements have been made for all staff to receive updated training in the use of and administration of medication. 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. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Current and prospective service users are provided with sufficient information to make an informed choice about where they live. The homes admissions procedure is sufficient to ensure that needs can be met. EVIDENCE: The home has a Statement of Purpose, Service user guide, and a written admissions procedure. The Service user guide is provided in a range of formats and one service user was able to show the inspector their information about the home and services provided in pictures and symbols. The admissions procedure includes a pre-admission assessment, visits and a trial period. Although the home has had no recent admission records did confirm that this procedure was followed for the last service user who moved to the home. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 9 Individual records are kept for each service user, and these contained, care plans and risk assessments. Service user files contained a contract between the home and the service user and these had been signed and dated. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10. Service users are encouraged and supported to make decisions and choices regarding their life and issues concerning the home. The homes risk assessment process ensures that service users are kept safe whilst participating in opportunities inside and outside the home. Service users can feel confident that their personal information is treated with confidence and kept safe. EVIDENCE: During the Inspection a sample of service user plans were seen. Each service user has a care plan and risk assessments, which are regularly reviewed. Any restrictions on choice or freedom were documented and had been agreed with the service user and other people involved in the individuals care. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 11 The Registered Provider said that due to the age of several service users and changes in health, the level of care required was becoming greater, particularly with daily personal care needs. Discussion took place with the Registered Provider regarding the need to ensure that the information in care plans and guidelines for staff reflect these changes. The staff on duty displayed a good understanding of service user needs and were observed supporting them to make choices about their care and plans for the day. Discussion confirmed that staff had been supporting one service user to consider plans for the future. Discussion took place with the Registered Provider about the benefits of Advocacy and Person-Centred-Planning to assist this process. Records relating to service users money were up to date and accurate. Service users are asked to contribute their Disability Living Allowance for the use of the homes transport, this information is stated in the service user guide and Statement of Purpose. Service user records and other information were stored safely and information seen during the inspection was found to be well maintained and up to date. Current service user plans were kept together in one file. This information should be stored separately to ensure confidentiality at all times. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,17 Service users are encouraged and supported to maintain and learn life skills, participate in community and leisure activities, and enjoy a healthy diet of their choice. The home supports service users to maintain contact with family and friends. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 13 EVIDENCE: Information in care plans, as well as discussion with service users and staff showed that they were enabled to live as full a life as possible and have a range of opportunities to develop and maintain skills. On the day of the inspection several service users were attending day- centres, visiting family or relaxing at home. The homes activity charts displayed a list of planned and leisure arrangements for service users, however, within individual care plans this information was limited and it was therefore not clear how this area of care would be monitored and reviewed. The Registered Provider said that several service users were spending more time in the home due to age and/or ill health. Records confirmed that advice and support had been provided by the specialist Learning Disability services regarding opportunities and activities within the home. This information should be documented within the service user can plan to ensure that staff are aware of how to support service users as their needs change. Service users are supported by the home to maintain their links with family and friends. On the day of the inspection one service user was looking forward to a visit home and staff were assisting this arrangement by providing transport. Where possible service users are involved in choosing meals, shopping and food preparation. Informal discussion and the use of pictures and symbols assist this process. Records confirmed that staff have to consider some special diets and this information is clearly documented. Staff were observed recording fluid and food intake and following guidelines for mealtimes as outlined in one service user plan. A written menu was available, which showed a balanced choice of meals and also listed personal preferences and individual arrangements for the day. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,21. Service users healthcare needs are monitored and any changes are addressed as soon as they are identified. Staff have a good understanding of the changing needs of service users due to age/illness and access services and training opportunities to ensure that needs continue to be met. EVIDENCE: Service user plans and records provided information about personal, emotional, and health care needs. Through discussion it was evident that this information was not always sufficient in detail for some service users with more complex health care needs. Discussion took place with senior staff and the Registered Provider about the need to ensure that as service users needs change and/or increase that records reflect this change and give clear guidelines to staff to ensure consistency of care. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 15 Service users health is monitored and potential problems are identified at an early stage. External professional advice and guidance was sought when necessary from local healthcare professionals and the specialist Learning Disability services. Examples were given of the home contacting Physiotherapy, Occupational Therapy and Dieticians regarding concerns about a service user. It was evident that staff were following guidelines and advice provided by these agencies, and the manager said that this had resulted in an improvement in the individuals health. The home regularly liaises with specialist teams for Dementia Screening and staff have undertaken training in Dementia care. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16, 18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 16, 18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Service users are protected from abuse, neglect and self- harm. Service users can feel confident that any complaints are taken seriously and all service users are given the opportunity to express their views and concerns. EVIDENCE: Neither the home nor the Commission for Social Care Inspection have received any complaints regarding the service since the last inspection. The home has a complaints procedure, which was available within the Statement of Purpose and Service User Guide. Staff displayed a good understanding of the individual communication methods of service users, and were able to use this knowledge to respond to requests and pick up on cues displayed in mood/ behaviour. The homes daily recording and key-worker system is also used to ensure that any concerns/problems are documented and can be addressed. The management and staff team were aware of Adult Protection issues, and training has been undertaken or is planned as part of a rolling programme for all staff. There is an Adult protection procedure in place, as well as a copy of the local Alerters Guide. A ‘quick glance’ flow chart is also available in the office to alert staff of what to do if they suspect an incident of abuse. Discussion with staff confirmed that some service users displayed behaviour that may be challenging. Records contained information from the specialist Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 17 Learning Disability services regarding behaviour, and behaviour management guidelines. It was not evident if this information was current and not all staff were aware if these guidelines needed to be followed. Service users have been assessed as requiring support with daily finances. Individual accounts have been set up and a clear record is kept of all in-coming and out-going expenditure. Service users contribute their Disability Living Allowance towards their transport and this is documented within the homes Statement of Purpose and Service user guide. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30. The home has sufficient space and facilities for the number and needs of current service users. Consideration is given to the changing needs of service users and alterations/adaptations are made to the environment when necessary. EVIDENCE: A tour of the premises took place and all service users bedrooms were seen during the inspection. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 19 The home has sufficient shared and communal space to accommodate the number and needs of service users living in the home. There are six single rooms and two double rooms and one service user requiring a wheelchair is accommodated on ground floor. The home was found to be clean and tidy and service user bedrooms contained personal items and sufficient furnishings. One of the bedrooms at the rear of the house had poor natural lighting and the Registered Provider should consider ways of how this could be improved. The Registered Provider said that the home has a rolling programme of renewal and decoration and a new carpet and sofa had been ordered for the communal lounge and dining area. Consideration was also being given to alterations, which may improve the communal space for service users particularly as needs change and increase. A range of equipment and adaptations were in place and the senior member of staff on duty said that the all equipment is regularly maintained. Advice is sought form the physiotherapist and Occupational Therapist when required. The ground floor and outside patio at the rear of the building have disabled access. Risk assessments had been completed for the need for water temperature valves, radiator covers, and window restrictors and the Registered Provider said that these had been fitted where a risk had been identified. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36. Staff are provided with a range of training opportunities relevant to the home and needs of individual service users. Staffing levels are sufficient for the number of service users living in the home. The homes recruitment procedures are robust and protect service users. Staff are well supported by each other, outside agencies and the management team. EVIDENCE: Staff demonstrated a good understanding of service users needs and most staff were observed responding sensitively and respectfully to service user needs and requests. Training records confirmed that staff attend a range of training opportunities relevant to the home and individual service users, and mandatory Health and Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 21 Safety training is updated regularly. Since the last inspection staff have completed training in the use and administration of medication. Details of NVQ qualifications were not inspected on this occasion. The Registered Provider advised that there is a total of 10 care staff and this includes seven day, and three night staff. There were three staff on duty on the day of the inspection and this included one senior care worker. One staff member spoken to said that several of the service users daily personal care needs had increased and staffing levels were not always sufficient to meet these needs at the busy times of the day, particularly the morning. Staff files inspected showed that the home has a robust recruitment procedure and all necessary checks had been completed. Of the sample of staff files seen Criminal Records Bureaux checks had been completed. All staff are provided with a contract of employment and job description. Regular staff meetings and formal supervision take place and this information is documented. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Staff are supported by a good system of management and receive formal and informal advice and support when needed. The homes record keeping, policies and procedures allow for the effective, and efficient running of the home and ensures the protection of service users. Service users rights, health, safety and welfare are protected and promoted. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 23 EVIDENCE: The Registered Manager, Mrs Dawn Bartlett was not available on the day of the inspection. A senior care worker was in charge of the shift, and Mrs Amanda Nicholson, the home- owner was present throughout the day. Mrs Nicholson is also the Registered Manager of a care home next door to Inglenook and is available to provide support to staff and management. During the inspection most of the staff on duty were open and supportive and demonstrated a good understanding of service user needs. In the absence of the Registered Manager, staff were able to assist with the inspection process and were aware of the homes policies and procedures. The home has a Quality Assurance system, which includes service user and relatives questionnaires. The results from questionnaires are discussed in team meetings and an action plan agreed. Records within the home were well maintained and the Registered Provider was aware of where information needed to be more detailed as service users needs change and increase. A system of monthly checks is in place to address health and safety in the home. Staff receive regular health and safety training as part of an on-going rolling programme. Risk assessments had been completed for water temperature valves, radiator covers and window restrictors. The Registered Provider said that necessary devices had been fitted where a risk had been identified. Door opening devices had been fitted in some parts of the house. The Registered Provider must ensure that all fire doors are kept shut when not in use. If fire doors are held open, the Registered Provider should seek advice to ensure that appropriate door opening devices are fitted. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 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. Where there is no score against a standard it has not been looked at during this inspection. 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 4 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT 37 X 38 3 39 3 40 3 41 3 42 2 43 X Standard No 6 7 8 9 10 LIFESTYLES 11 12 13 14 15 16 17 Score 3 3 3 3 3 3 3 3 2 3 X 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 X 3 Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 25 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. Standard Regulation Requirement Timescale for action 10/11/05 1 YA42 23 The Registered Provider must ensure that fire doors are kept closed. If fire doors are held open the Registered Provider must ensure that appropriate devices are fitted. 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 YA10 YA14 Good Practice Recommendations Care plans containing personal and private information should be filed separately for each service user to ensure privacy of information at all times. As service user needs change and increase and they are spending more time in the home, care plans should be updated to ensure that staff are aware of how they are supporting them and what activities they are doing during the day. The Registered Manager should ensure that as service DS0000003533.V251998.R01.S.doc Version 5.0 Page 26 3 YA18 Inglenook House 4 YA23 5 YA32 users personal and healthcare needs become more complex that the care plans reflect this change and give clear guidelines to those providing care. The Registered Provider should ensure that staff are aware of and understand any agreed guidelines relating to service users behaviour. This information should be available in a format that is accessible and clear to those providing care and can be monitored and reviewed on a regular basis. The Registered Provider should ensure that there is a process for reviewing staffing levels and ensuring that staff numbers are sufficient to meet the current and changing needs of service users. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Inglenook House DS0000003533.V251998.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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