Inspection on 30/01/08 for Kingswalden Villa

This inspection was carried out on 30th January 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kingswalden Villa 16/01/09

Kingswalden Villa 16/02/07

Kingswalden Villa 06/02/06

Kingswalden Villa 22/08/05

Kingswalden Villa 13/01/05

Kingswalden Villa 07/06/04

Kingswalden Villa 12/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Kingswalden Villa 40 The Baulk Biggleswade Bedfordshire SG18 0PX Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 30th January 2008 10:20 Kingswalden Villa DS0000014921.V359029.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 Kingswalden Villa DS0000014921.V359029.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. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingswalden Villa Address 40 The Baulk Biggleswade Bedfordshire SG18 0PX 01767 318674 F/P 01767 318674 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) www.hft.org.uk Home Farm Trust Mr Ian Chambers Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2007 Brief Description of the Service: Kings Walden Villas is one of five registered care homes within Bedfordshire that are managed by Home Farm Trust. HFT is a nationwide provider for people with learning disabilities. Kings Walden Villas is situated in a residential area of the market town of Biggleswade, and is a short distance from the local HFT headquarters and day care facility in Shefford. The home is within walking distance of the towns shops, public houses, cafes, and bus and rail links. A leisure facility with swimming pool is a short car journey away. The home does not have off road parking. The building was originally used as a private domestic dwelling. It has been sympathetically converted to retain its homely environment, and provides single accommodation to eight adults with learning disabilities organised on two levels. Communal space consists of toilet and bathing facilities, a lounge, dining room, and kitchen. In addition, at the rear of the property is an all weather conservatory that leads to a small-enclosed garden. Within the garden, is an outbuilding used for storage and laundry. The home is not currently adapted to accommodate people with physical disabilities. Information regarding the home’s range of fees and the manager’s figure provided in the pre-inspection questionnaire in January 2007 stated that the monthly fee ranged from £2098.40 to £2609.78. Any additional fees not included were also specified and that they would incur an additional charge. The home had reduced from 8 beds to 7 beds and has asked the commission for an amended certificate of registration. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 30/01/08 by Pursotamraj Hirekar over 6 hours 30 minutes. The manager coordinated the inspection. The method of inspection included study of care plans, risk assessments, staff deployment duty rota, relevant care delivery documents, and discussions with staff, conversation with service users’ and partial tour of the building. Letter and documentary evidence received from the service manager, in response to the feedback given on inspection, are included for analysis and preparation of this report as well. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure the care plans accurately reflected service users changing needs and associated risks to enable the home to meet those needs and minimise risk to service users. Training must be provided for staff by the home, which is appropriate for the work they are to perform especially food hygiene practices. Arrangements must be made to ensure that all the work planned for the maintenance of the safe environment is carried out on time. The home must make appropriate arrangements to complete implementation of all the recommendations made by the fire authorities on time. The home must evidence clear purpose of all carer medication notes written on the back of the MAR sheet. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 6 The home must ensure that service users health action plans are completed and associated service user plan were signed by the service user or their representative to acknowledge their consultation and agreement, to safe guard the health and well being of people using the services. The home must ensure that nutritional assessments are carried out and are reflected in their care plans to evidence dietary needs and choices are considered suitably for each individual service users’ and that is reflected in their daily food menu. The home should regularly explain the complaints procedures to each service user in an appropriate language that they understand. Arrangements should be made to ensure that service user plans are made available in a suitable format that the service user can understand. 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. Kingswalden Villa DS0000014921.V359029.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 Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided information about its facilities and services, which were supported by needs assessments to enable prospective service users to make an informed decision about admission to the home. EVIDENCE: The homes service user guide was available in a suitable format for some of the service users intended and provided information to enable prospective service users to make an informed choice about where to live. Service users who were spoken with as part of the inspection supported that evidence. The manager informed on this inspection, that the home plans to revise service user guide and the statement of purpose to further improve its presentation with more pictorial based information. There was evidence that the home had assessed the needs of a prospective service user and demonstrated that the method and system for doing so provided a satisfactory form of assessment. The method of assessment involved the service user, the family, and other individuals referred to as part of the service users care management process. There has been no new admission since the previous inspection. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user care plans needed further development to ensure both the plans, and risk assessments were reviewed and updated at regular intervals. To ensure they accurately reflected service users changing needs and associated risks to enable the home to meet those needs and minimise risk to service users. EVIDENCE: A sample of the service users plans and supporting documentation were examined and found they did not contain suitable and sufficient information to help meet their changing needs and personal goals were identified and reflected in their individual plan. For example, a service user care plan review held on 30/11/07 identified an action to refer the service user to art & music therapy and psychology, as on this day of inspection, this was not reflected in the care plan and neither a referral was made. The manager informed that he would refer ASAP. A key worker was allocated for each service user. In the discussion of 23/01/08 between a staff member and person using the service regarding personal safe hygiene practices, which was recorded in detail in the daily notes. However, this was not reflected in the care plan and there was no evidence provided, as to what follow-up action was taken, to prevent the Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 10 potential risk of infection control from unsafe practices. The key worker spoken to have confirmed that, this incident was not followed up. There was evidence that the plans had been reviewed, not all service user plans demonstrated evidence that the service user together with their family, friends and / or advocate as appropriate had been consulted and several had not been dated or signed by the staff member completing the information to validate them. There was evidence from speaking with service users and records examined that service users were assisted as necessary to make decisions about their daily lives. Staffs were observed communicating in ways appropriate to each individual service user, to enable them to make an informed decision in a way the service user could understand. It was evident by observation, that service users were offered the opportunity and participated in the day to day running of the home and contributed towards any proposed changes within the home, to influence any decisions reached. A sample of risk assessments were seen and found that the home enabled service users to take risks supported by staff. There was evidence that service users who were self-administering their own medication had been risk assessed to ensure their safety. A risk assessment identifying the hazards to individual service users, of the external laundry and its associated equipment and chemicals in a separate out building was also carried out. However health action plans had limited value because those examined had not been regularly reviewed, dated, or signed. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home and staff support the service users to pursue meaningful leisure activities, education, relationships, and community links. In the absence of strict adherence of home’s frozen food policy and procedures and nutritional needs assessment, people using the service, their health and wellbeing may not be well maintained. EVIDENCE: The home supported service users to attend college and many were also supported by the home to regularly visit a resource centre, which provided planned educational and training activities; also a local leisure centre, library, cinema and access a range of holistic natural therapies provided locally. The Internet was also provided and used by service users within the home for educational as well as leisure purposes. The home’s notice board for service users displayed information about local activities. Service users were able to access and use local public transport facilities available close to the home; one service user used public transport to travel to college each day. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 12 There was evidence that the home supported service users to maintain family links and friendships inside and outside the home, in accordance with their wishes. Staffs was observed knocking on service user’s bedroom doors before entering and waiting to be invited into their bedrooms. Those service users who wished to be supported to keep their own room keys. Service users responsibility for housekeeping tasks was specified within a rota devised by the homes service users. One service user explained that each service user took it in turn to complete a task, which they believed was fair and the tasks rotated at regular intervals. The home had recently updated food policy and procedure for frozen food consumption. It was found on this inspection that, the staff on duty had not followed the correct procedures for frozen food. For example, chicken that was bought on 24/01/08 had printed instruction on the box that said, use by 28/01/08 and suitable for freeze on day of purchase and use within 1 month, defrost thoroughly before use and use within 12 hours. This chicken was not used within 12 hours. This was supported by hand written evidence pasted on the box, which contained chicken. The evidence was shown to the manager and was discussed; the manager had immediately disposed of it. The staff member on duty, who was not available during the discussion, later asked why the chicken was destroyed. The manager told her to read the policy and procedure again, which she did and agreed with the decision. There was evidence that not all service users nutritional needs were being assessed to consider, as part of the menu planning for a balanced diet. Although, the menus were not in a suitable format, to enable, all service users to make an informed choice. Not all service users had the opportunity to be involved in devising the fortnightly menus, however service user’s who were supported by staff to undertake the food shopping were rotated to include all service users. Service users were observed being supported by staff to clean and tidy up after the meal. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The system and practices for the administration of medication were satisfactory, except in one case whose MAR sheet carer medication notes purpose was not clear. The home needed to ensure that service users health action plans are completed and associated service user plan were signed by the service user or their representative to acknowledge their consultation and agreement, to safe guard the health and well being of service users. EVIDENCE: Service users spoken to said they enjoyed living at the home and that they felt supported by the staff. Records viewed suggested service users received personal support in the way they preferred and most were encouraged to maximise their independence. This was supported by observations and discussions held with service users. Each service user had a key worker, who they were each able to identify and those service users spoken to said they were happy with the support from them and the relationship they had developed with them. One service user said “the staff always speak nicely to me and they are helpful’ and ‘an other service user said, my key worker is not working today, I will talk to the manager’. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 14 There was evidence that the home accessed outside healthcare professionals and services as required; in order to support and meet the healthcare needs of the service users. Further development was required to ensure that the health action plans for individual service users were completed in full by the home and reviewed. The associated service user plan had not been signed by the service user or their representative to acknowledge their consultation and agreement. The home had ensured that care staffs were trained in medication and the procedures implemented suggested that service users safety was being maintained in most areas. Staff observed supporting service users with and administering medication to service users appeared competent and confidant. There was evidence that 1 service user self-administering own medication had been risk assessed, the staff member and the person using service both sign the MAR sheet. 1 service user’s MAR sheet had hand written notes on the backside dated 20/01/08 which recorded very big quantity of medicine as carried forward and initialled by a staff member, the purpose of this information was not clear what it meant. The manager was also not sure what this carer’s medication notes meant. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for protecting service users were good, and the home need to help people using services, to be fully aware of the complaints procedure and keep them reminding on a regular basis, to ensure people using services were protected from abuse, and to feel that their views were listened to and acted upon. EVIDENCE: The home had a satisfactory complaints procedure that ensured service users felt their views were listened to and acted upon. The complaints procedure was produced in a format appropriate for service users to understand and access. There had been no complaints since the last inspection. The home had a Safeguarding of Vulnerable Adults (SOVA) policy in place, which included whistle blowing and staff spoken to demonstrate they were aware of the procedure. Most staff had also attended abuse awareness training, which included SOVA; SOVA training was also included and formed part of the homes induction process for staff. Since the last inspection there had been no notifiable incidents at the home in accordance with the SOVA policy and guidance, which required reporting to the commission. . One service user spoken to on this inspection wanted to know, what should they be doing, incase the staff member or the manager do not listen to them. The manager intervened and said that, in a situation, if the staff or the manager does not listen, they can complaint to the commission. However, people using the service had no complaint to make. They were interested in knowing the procedure. The home need to help them, to be fully aware of the complaints procedure and keep them reminding on a regular basis, to ensure, people Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 16 using services were protected from abuse and to feel that their views were listened to and acted upon. The homes policies and practices regarding service users money and financial affairs were generally satisfactory and protected service users from abuse. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home was satisfactory. The home should action all the outstanding fire and occupational therapist recommendations in a timely manner, to improve, to maintain a pleasant and safe environment for service users. EVIDENCE: The home provided a homely environment; the building had been sympathetically converted from private houses. The location and layout of the home were suitable to meet service users individual and collective needs. The home was close to local amenities and transport if required. The manager evidenced that he was following up the recent fire inspection report of 21/12/08 recommendations, with the help of service manager and estates. Service users spoken to were happy with their individual bedrooms and they had free access to them. Service users had been encouraged to bring or choose their own furniture and those bedrooms observed had been personalised to reflect their needs and lifestyle. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 18 Toilets and bathrooms were safe for their intended purpose and were in appropriate locations. Each was lockable and maintained service users privacy, however staffs were able to override this feature in an emergency. Occupational therapist, report of dated 28/07/06 recommended that a shower toilet be considered. It would be appropriate for it to be installed in the bathroom chosen to be adapted. This has not been done. The manager informed on this inspection and provided some documentary evidence, which said the bathroom adaptation work, was likely to be started on the 11/02/08. The home appeared clean and generally free from offensive odours, service users, care staff and night staff were responsible for ensuring this was maintained. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing numbers to meet the needs of the service users were satisfactory during the week, however this was not always the case at weekends. Should there be any significant change in need of individuals in the service, or should there be a change in who is living at the service the staffing levels should be reassessed to ensure the health, safety, and wellbeing of service users. EVIDENCE: Staff spoken to identify varied training which they had undertaken at the home and this was supported by evidence in their training records. There was evidence that some staff had received specialist training to support them to meet the needs of the service users. The percentage of staff qualified at nvq (national vocational qualification) level 2 or 3, were well above the minimum required level of 50 . Evidence from speaking to staff and examining the homes training records supported that the staff training and development plan that was in place, needed update. Staffing level numbers within the home were maintained to meet the appropriate ratio based upon the needs of the service user during the weekdays. However staffing level numbers fluctuated based on how many service users were in the home, they sometimes reduced at the weekends Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 20 particularly if several service users had gone away. Staff numbers were regularly falling below the ratio required during some weekend evenings. Basing on the feedback given to the manager and the service manager, during the inspection, the commission had received a letter from the service manager dated 31/01/08, which stated that ‘ number of available placements has reduced from 8 to 7. Since the change in the number of people living at the service the staffing levels have been maintained. A staffing ratio of 1:6 is considered acceptable at any time based on the needs of the people currently living at the home. There are also certain periods of time when a ratio of 1:7 is sufficient based on the Support needs of existing service users. If there were 7 people in the house during the day 2 staff would usually be on shift. HFT will continue providing this level of support at the service for the existing service users based on their support needs at this time. Should there be any significant change in need of individuals in the service, or should there be a change in who is living at the service the staffing levels would be reassessed’. A sample of staff’s documents indicated that, the homes recruitment processes and practices were satisfactory. There was evidence that the home maintained a low turnover of staff and agency staff usage. Staff spoken to documents seen supported that they received regular supervision. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some aspects of the homes health & safety, safe working practice procedures needed timely action to ensure service users & staff would be protected from the risk of harm. EVIDENCE: The manager had coordinated the entire inspection. There was evidence that the manager was qualified, competent, and experienced to run the home. Some aspects of the homes health & safety safe working practices, required some improvements to protect service users from potential risk or harm. See ‘Environment’ outcome group of this report. Various records were examined to support adequate compliance with safe working practices, regarding health & safety including generic risk assessments for the home and various tasks. The manager was following up the recent fire inspection report of 21/12/08 recommendations, with the help of service manager and estates, the manager informed on this inspection. Occupational therapist, report of dated 28/07/06 Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 22 recommendations was scheduled to be actioned in the second week of February 2008. The home used a traffic light hazard warning system for storage and control of substances hazardous to health (COSHH). A risk assessment identifying the hazards to individual service users, of the external laundry and its associated equipment and chemicals in a separate out building was carried out. The home had introduced an internal quality assurance system that was aligned with the national minimum standards outcome groups, a sample was seen on this inspection and found satisfactory. The home had also carried out detailed regulation 26 visit that monitored provision and delivery of services. However, the home needed to evidence, how some the identified needs from the regulation 26 visits have been actioned. For example health action plan completed in 2006 no evidence that this has been reviewed. The home had written to the commission to reduce from 8 beds to 7 beds and issue an amended certificate of registration. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 24 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 YA6 Regulation 15 (1) Requirement Timescale for action 30/03/08 2. YA32 18 (1) (c) & (i) The home must ensure the care plans accurately reflected service users changing needs and associated risks to enable the home to meet those needs and minimise risk to service users. Training must be provided for 29/02/08 staff by the home, which is appropriate for the work they are to perform especially food hygiene practices. Arrangements must be made to ensure that all the work planned for the maintenance of the safe environment is carried out on time. The home must make appropriate arrangements to complete implementation of all the recommendations made by the fire authorities on time. The home must evidence clear purpose of all carer medication notes written on the back of the MAR sheet. The home must ensure that DS0000014921.V359029.R01.S.doc 3. YA24 23 (2) (b) 30/03/08 4. YA42 13 (1) (a) 30/03/08 5. YA19 12 29/02/08 6. YA20 12 30/03/08 Version 5.2 Page 25 Kingswalden Villa 7. YA17 13 (5) & schedule 3 service users health action plans are completed and associated service user plan were signed by the service user or their representative to acknowledge their consultation and agreement, to safe guard the health and well being of people using the services. The home must ensure that nutritional assessments are carried out and are reflected in their care plans to evidence dietary needs and choices are considered suitably for each individual service users’ and that is reflected in their daily food menu. (Previous time scales – 30/04/07) 30/03/08 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 YA22 YA6 Good Practice Recommendations The home should regularly explain the complaints procedures to each service user in an appropriate language that they understand. Arrangements should be made to ensure that service user plans are made available in a suitable format that the service user can understand. Kingswalden Villa DS0000014921.V359029.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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