Inspection on 23/08/06 for Litslade Farm

This inspection was carried out on 23rd August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Litslade Farm 30/03/06

Litslade Farm 29/06/05

Litslade Farm 22/03/05

Litslade Farm 24/05/04

Litslade Farm 20/11/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Litslade Farm 2 Bletchley Road Newton Longville Bucks MK17 0AD Lead Inspector Sue Smith Unannounced Inspection 17th August 2006 09:30 DS0000023077.V308381.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 DS0000023077.V308381.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. DS0000023077.V308381.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Litslade Farm Address 2 Bletchley Road Newton Longville Bucks MK17 0AD 01908 648143 01908 648143 litslade@nildram.co.uk 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) Hightown Praetorian & Churches Housing Association Mrs Olive Bateman Care Home 5 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places DS0000023077.V308381.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 people, learning disabilities, physical disabilities Date of last inspection 30th March 2006 Brief Description of the Service: Litslade Farm is a small community home providing care and support to 5 Service Users with learning disabilities. The home is situated in the small village of Newton Longville, within driving distance to the Bletchley local amenities and Milton Keynes City Centre. The home is a bungalow that has been adapted to meet the long-term needs of the Service Users, situated in a pleasant and well-maintained garden. The Manager is suitably qualified and experienced to undertake her role, providing a high quality service to vulnerable Service Users. DS0000023077.V308381.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection of the service since the implementation of IBL2 (Inspecting for Better Lives). The inspection was undertaken on the 23rd August 2006 by Sue Smith (Regulatory Inspector). The Manager or Senior Team Leader (Deputy) was available throughout the inspection. The Inspector used a triangulated methodology to complete this inspection, pre-inspection information and documentation was used in the planning process to ensure hypothesis were formulated to support the inspector to explore issues of concern and verify practice and service provision. During the inspection a variety of documentation was assessed, which included Careplans, Risk Assessments, Monitoring tools, Medication procedures, Rota’s, Recruitment files and Training records. The Inspector for Case Tracking purposes identified two Service Users. As a result of this inspection two requirements and three recommendations were made to support the home to further improve its practice. The Service Users at Litslade Farm have limited communication skills, which necessitated the Inspector spending time observing the practice of staff and how they interacted with the Service Users. Throughout these observations the Inspector found staff to be professional when carrying out their duties, the Service Users were relaxed and enjoyed the company of the staff. Staff work hard to provide a homely and relaxed atmosphere for Service Users. On the day of the Inspection the Inspector was able to meet with the Advocate for the Home who was conducting a residents meeting to gain her views of the home. The Advocate provided the inspector with information as to how the views of Service Users are voiced and her observations of the Service, she had recently been in discussion with the management team on how to improve on the activities offered to Service Users. She finds the management team approachable and works well with them as an additional and much needed voice for the Service Users. The Advocate has a positive relationship with the Service Users as a group and can be called upon should an individual need be identified. Feedback was received from families through comment cards as well as one visiting family, feedback was positive on all comment cards with the visiting family happy with the opportunities that have been offered to their family member since living at the home. They have noticed improvements in his individual living skills since being at the home and praised the Management and the team for their hard work in providing a pleasant and enjoyable home life to the Service Users. DS0000023077.V308381.R01.S.doc Version 5.2 Page 6 The Inspector would like to thank the Service Users Staff and Management for the warm welcome received, and their continued support in completing the inspection. What the service does well: The Organisation operates a thorough pre-admission procedure, which is reflective of consultation with the Service Users, and other agencies to ensure only appropriate admissions are made, The home provides individual plans of care for Service Users, which ensure their needs, and aspirations are reflected and reviewed. Service Users are supported to take part in a variety of meaningful and enjoyable activities, which ensure they are able to access the local community and become part of village life. Relationships and family contact is supported by the home to ensure the Service Users are able to maintain their ties with family and friends. Service Users rights and responsibilities is promoted at the home ensuring the Service Users are given the opportunity to build on their levels of independence. Menus are developed with the Service Users ensuring all meals are nutritiously balanced and reflective of the likes and dislikes of Service Users. The home ensures the healthcare needs of Service Users are identified and referrals are made to specialist therapists or the G.P. thus ensuring the ongoing and changing healthcare needs of Service Users is met. The home has robust medication procedures in place, which protect the Service Users. The home has a comprehensive complaints procedure which is reflective of timescales for action, this supports service users and significant others to make complaints appropriately. The home follows the local authority Protection of Vulnerable Adults Policy and its reporting procedures, ensuring the ongoing safety of the Service Users. The home ensures training is in place to support the professional development of all staff, therefore ensuring the ongoing protection of Service Users. DS0000023077.V308381.R01.S.doc Version 5.2 Page 7 The home has a thorough recruitment procedure, which is reflective of good practice, ensuring all security checks are in place prior to employment to further protect service users. A suitably qualified and experienced manager who ensures the home is run in the best interest of the Service Users manages the home. The home has quality audit systems in place, which help to maintain the homes systems and provide an annual improvement plan for the home, ensuring the home continues to provide the best possible service to its Service Users. The home has systems in place, which protect the Health, Welfare and Safety of the Service Users. What has improved since the last inspection? What they could do better: The scheduled work to improve the environment does need to take place, as soon as is reasonably practicable to ensure the home maintains it’s high standard. DS0000023077.V308381.R01.S.doc Version 5.2 Page 8 The Manager will need to inform the Commission of the outcomes of the planned interviews for prospective staff, any interim measures will need to be conveyed to ensure the home is staffed within its stated numbers. A new hard wiring certificate is due, the planned date for this inspection is the 6th September 2006, once this has been undertaken and a certificate is issued a copy will need to be forwarded to the Commission to be held on file. Although the Careplans are maintained to a high standard, the way in which information is required to be stored by the Organisation needs to be further reviewed as it can be somewhat confusing when working from 2 to 3 files when reviewing and assessing information. Equipment that has been fitted at the home to address the future needs of Service Users e.g. call bells and assisted baths, need to be subject to a checking system at least 3 monthly to ensure they are in good working order should they be required. The Manager ensures the training needs of staff are identified and courses are sought, however the current system can be time consuming, therefore the Inspector has recommended a training matrix that can be stored on the homes computer be developed to support her to manage this task more efficiently. 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. DS0000023077.V308381.R01.S.doc Version 5.2 Page 9 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 DS0000023077.V308381.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. 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 the service. The Organisation operates a thorough pre-admission procedure, which is reflective of consultation with the Service Users, and other agencies to ensure only appropriate admissions are made, ensuring the protection of Service Users. EVIDENCE: The Organisation has a thorough admissions procedure in place; this is reflective of consultation with the Service User and relevant agencies to ensure the home is able to meet the present and ongoing needs of the Service User. At this time there have been no admissions to the home in the past three years, therefore the procedures have not recently been tested for this service. The Manager had a clear understanding of the admissions procedure and how to ensure the best interests of the potential Service User and the existing Service User group would be taken into account for any future admissions. The home has a designated Advocate who supports the Service Users and would be available should the need arise to support the admissions procedure. DS0000023077.V308381.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The home provides individual plans of care for Service Users, which ensure their needs, and aspirations are reflected and reviewed. EVIDENCE: Individual plans of care are in place, which are reflective of the ongoing and changing needs of Service Users. These plans are written in a manner that outlines the personal preferences of the Service User and how best to achieve the required outcomes. The plans include daily diary notes, which were found to be informative. In addition the plans include lifestyle plans, record of activities, family and friends contact sheet, monthly weight monitoring sheets, seizure records, risk assessments, deciding on support plans, Dr and Nurse appointments, correspondence and other health care appointments. Some plans were due for review with the recommended date for review reflected. Discussion took place with the Manager for the need to ensure when a Service User has an accident causing an injury, which requires additional intervention; these actions must be reflected in an additional support plan to ensure all staff DS0000023077.V308381.R01.S.doc Version 5.2 Page 12 are providing a consistent approach to care. As this issue only pertained to one Service User and there was clear documentation elsewhere as to how this persons needs were met, a requirement has not been made at this time. The Organisation provides a format to which staff follow to ensure Careplans are maintained appropriately, this system provides two folders with specific information relating to the care of the individual, in addition a separate finance folder is available for use. The use of these files can be somewhat confusing when assessing and reviewing the care provided to an individual. In some instances there does not seem to be a clear rationale as to why information is stored in a separate file, for example duplicates of risk assessments. This is something the Organisation needs to address to ensure the best possible system for the storage of information is in place at its projects, which is easy to manage by the homes staff, and provides a clear audit trail. A recommendation is made that the Organisation reviews where information is stored to ensure a clear audit and review system can be implemented. DS0000023077.V308381.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. Service Users are supported to take part in a variety of meaningful and enjoyable activities, which ensure they are able to access the local community and become part of village life. Relationships and family contact is supported by the home to ensure the Service Users are able to maintain their ties with family and friends. Service Users rights and responsibilities is promoted at the home ensuring the Service Users are given the opportunity to build on their levels of independence. Menus are developed with the Service Users ensuring all meals are nutritiously balanced and reflective of the likes and dislikes of Service Users. EVIDENCE: DS0000023077.V308381.R01.S.doc Version 5.2 Page 14 The home continues to provide a variety of activities that are both meaningful and enjoyable to Service Users. Recent discussion has taken place between the home and the Advocate as to how best improve on these activities in line with the needs of the Service Users. Service Users are given the opportunity to access their local community as and when required as well as programmed activities which support them to be part of the community. In addition Service Users continue to access the local college with minimal support. The homes staff have worked hard over the past years to establish the home as a recognised part of village life, they are involved in the local church and attend regular services and functions (by invitation) and are well known for their baking skills providing the winning entry at last years church fete and are hoping to do as well in this years competition. Menus are planned with the Service Users and are reflective of a well balanced diet taking into consideration the likes and dislikes of the Service Users. Home baking, snacks and regular fluids are provided as and when Service Users wish. The home consult with the Learning Disability Dietician to support the ongoing and changing needs of Service Users with action plans reflected in the Careplans. DS0000023077.V308381.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The home ensures the healthcare needs of Service Users are identified and referrals are made to specialist therapists or the G.P. thus ensuring the ongoing and changing healthcare needs of Service Users is met. The home has robust medication procedures in place, which protect the Service Users. EVIDENCE: Staff ensure all healthcare needs are met by supporting them to attend appointments, which is well documented in the Careplans. Additional therapists and support are identified as and when required and the home has a supportive G.P. service. Staff are respective of the privacy of Service Users, knocking on doors before entering and involving Service Users as far as they are able in the maintenance of their personal hygiene needs. All personal care is undertaken in the privacy of the Service Users bedroom or in the communal bathrooms. Staff have a clear understanding of the individual needs of the Service Users DS0000023077.V308381.R01.S.doc Version 5.2 Page 16 and treat them with respect whilst helping them to build on their independence skills. The home has a clear medication policy, which is reflective of additional guidance to support Service Users. Staff due to the needs of the Service Users administer all medication. Medication is stored, administered and recorded appropriately with no gaps evident on MAR (medication administration record) sheets. Dates of opening are present on all bottles and there were no out of date medications found in the home. A returns system is in place. All staff receive training, which includes a practical assessment of competence, the Manager ensures no staff member is permitted to administer medication until they have been assessed as competent. DS0000023077.V308381.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The home has a comprehensive complaints procedure which is reflective of timescales for action, this supports service users and significant others to make complaints appropriately. The home follows the local authority Protection of Vulnerable Adults Policy and its reporting procedures, ensuring the ongoing safety of the Service Users. EVIDENCE: The home operates a clear complaints procedure, which is reflective of timescales for action. There has been one complaint received since the last inspection, which was reported under POVA by the home. In addition the home has received one verbal concern due to recent flooding of a neighbours garden due to problems with the homes down pipe, this has been reported to the maintenance department for action. The home follows the Buckinghamshire Inter Agency policy for the Protection of Vulnerable Adults. There has been one POVA investigation carried out in the past 12 months, which was appropriately reported by the Manager and investigated fully. The report was not upheld, however actions have been put in place to ensure the ongoing safety of Service Users. Full details of this POVA complaint and actions taken were open to inspection. DS0000023077.V308381.R01.S.doc Version 5.2 Page 18 Staff have a clear understanding of what constitutes abuse towards Service Users and receive training and support which ensures the ongoing safety of the Service Users at Litslade Farm. DS0000023077.V308381.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29, 30 Quality in this outcome area is adequate; this judgement has been made using available evidence including a visit to the service. The project is pleasant and homely providing a safe environment, however redecoration does need to take place to ensure the standards are maintained for Service Users. EVIDENCE: The home is situated over one-floor providing open plan communal areas for Service Users to enjoy. The home is well equipped to meet the needs of the Service Users and is reflective of a homely and pleasant environment. Service Users bedrooms are personalised and are reflective of the individual’s personalities, hobbies and interests. Generally the home is well maintained but is in need of a complete redecoration to ensure it maintains its standard. Quotes to re-decorate the home have now been submitted and work will be scheduled as soon as is reasonably practicable. The home received a requirement at the last inspection to submit a plan for when the bathroom will be repaired and re-decorated, this work was included DS0000023077.V308381.R01.S.doc Version 5.2 Page 20 in overall quotes for the redecoration programme, however the Organisation failed to inform the Commission of this which left them in breach of the requirement. This was discussed with the Manager on the day of inspection and communication was made between herself and the estates department to resolve this issue. In the absence of the usual Senior Manager for the project Mrs Dianne Bird (Senior Manager) actioned the follow up of this issue and ensured the relevant correspondence was sent to the Commissions office. At the time of writing this report the Commission are satisfied this requirement has been met. The Organisation is reminded for future practice to ensure all requirements are fully actioned within the recognised timescales. The home was found to be cleaned to a high standard and was free from offensive odours. There were no identified hazards on the day of inspection with all items of C.O.S.H.H. kept in locked cupboards to maintain the safety of Service Users. The home has been fitted with equipment and adaptations which will support Service Users in the future should their personal needs increase, this includes a hoisted bath and a call bell system both of which are not used by Service Users at this time. On the day of inspection it was found that one of the call bells situated in the toilet was not working and will need repairing. As this equipment is presently not in use and therefore is not putting the Service Users at risk, a requirement has not been made. This fault has been reported to the home and will be sent to the maintenance team for repair. It is recommended a three monthly checking system be implemented to ensure these are always in good working order in the event they may be required. DS0000023077.V308381.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is adequate; this judgement has been made using available evidence including a visit to the service. The home ensures training is in place to support the professional development of all staff, therefore ensuring the ongoing protection of Service Users. Suitably qualified and experienced staff are employed at the home, however until the successful employment of soon to be interviewed staff takes place the home have a large number of vacancies, which could compromise care delivery. The home has a thorough recruitment procedure, which is reflective of good practice, ensuring all security checks are in place prior to employment to further protect service users. EVIDENCE: Presently the home has four full time members of staff and one part time member of staff as well as the Manager. The home currently has three full time and one part time post vacancies, interviews for these posts are taking place on the 29/8/06, and it is hoped successful applicants to fill these posts will be found. In the interim regular agency staff who are familiar with the needs of the Service Users are available to the home should permanent staff not be able to fill any gaps on the rota. A requirement is made for the Manager to inform the Commission in writing of the outcomes of the planned DS0000023077.V308381.R01.S.doc Version 5.2 Page 22 interviews to fill the vacant posts, and the actions that will be taken to ensure the home is staffed by suitable numbers until start dates are given. A record of all training undertaken by staff is held, this is currently held under individual names with the Manager regularly checking to ensure all mandatory training is kept up to date. The Inspector recommends a training matrix is formulated on the homes computer to support an easier and more efficient way of tracking training. Currently training undertaken includes Abuse, Care of Medicines, Moving & Handling, Food & Hygiene and Epilepsy. Future training includes Emergency First Aid, Fire Awareness, Welcoming Diversity, Understanding Mental Health and Appraisals. All other Mandatory training updates are booked as and when they are required with a rolling programme in place. The home operates a thorough recruitment system with records of all recruitment information held in the home. The Manager is involved in the short-listing of candidates and the interview process. All information is sent centrally and then forwarded to the Manager on completion. There were no gaps in the information held in the home, with CRB disclosures and two references held on file for all staff. DS0000023077.V308381.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. A suitably qualified and experienced manager who ensures the home is run in the best interest of the Service Users manages the home. The home has quality audit systems in place, which help to maintain the homes systems and provide an annual improvement plan for the home, ensuring the home continues to provide the best possible service to its Service Users. The home has systems in place, which protect the Health, Welfare and Safety of the Service Users. EVIDENCE: The home Manager has been in post since the home opened, previously working with these Service Users at Manor Hospital. She has the necessary DS0000023077.V308381.R01.S.doc Version 5.2 Page 24 qualifications and experience to support her in the role, which includes her Registered Managers Award and Nursing qualifications. The Manager ensures she updates her own professional practice through a variety of training sessions. The Home has an improvement/business plan, which is formulated each year; this outlines a variety of areas to support the home to improve its service. Other quality audit systems in place include Regulation 26 visits with reports sent to the Commission on a monthly basis. Individual Service Reviews which include management of the Team, areas of development and staff and team development. All Service Users Careplans are annually reviewed with necessary external agencies invited to discuss the progress of the Service User and future plans. Health and safety audits and reporting are in place, which include accident reporting. The home ensures the health, safety and welfare of Service Users is maintained through a variety of systems, which are in line with current guidance. On the day of inspection there were no hazards identified throughout the home and all items of C.O.S.H.H. were stored appropriately. Fire prevention systems are in place, which include a weekly check of all alarms and fire drills that take place at least twice a year. Contractors are employed to service all equipment with service records open to inspection. The home does need to ensure a copy of the new hard wiring certificate is submitted to the Commission as soon as the contractor has visited the home on the 6th September 2006. A requirement is made to this effect. DS0000023077.V308381.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 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 2 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X DS0000023077.V308381.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA33 Regulation 18 (1) a Requirement A requirement is made for the Manager to inform the Commission in writing of the outcomes of the planned interviews to fill the vacant posts, and the actions that will be taken to ensure the home is staffed by suitable numbers until start dates are given. Timescale for action 20/09/06 2 YA42 42 (3) iii A requirement is made that the 20/09/06 Manager submits a copy of the new hard wiring certificate to the Commission as soon as the contractor has visited the home on the 6th September 2006. 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 Refer to Standard YA6 Good Practice Recommendations A recommendation is made that the Organisation reviews where information is stored in the Careplan folders to ensure a clear audit and review system can be DS0000023077.V308381.R01.S.doc Version 5.2 Page 27 2. YA29 implemented. It is recommended a three monthly checking system be implemented for all fitted equipment currently not required by the Service Users to ensure these are always in good working order in the event they may be required. The Inspector recommends a training matrix be formulated on the homes computer to support an easier and more efficient way of tracking training. 3 YA35 DS0000023077.V308381.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 DS0000023077.V308381.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!