CARE HOME ADULTS 18-65
Melbreck Tilford Road Rushmoor Farnham Surrey GU10 2ED Lead Inspector
Nancy Gates Unannounced Inspection 14th November 2007 09:30 Melbreck DS0000017623.V347694.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 Melbreck DS0000017623.V347694.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. Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Melbreck Address Tilford Road Rushmoor Farnham Surrey GU10 2ED 01252 793474 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) melbreck@robinia.co.uk Robinia Care Limited Lorna Oliver Care Home 26 Category(ies) of Learning disability (26), Physical disability (26) registration, with number of places Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Twenty six (26) beds providing nursing care for people from the age of 19 years with learning disabilities (LD) and physical disabilities (PD). 22nd June 2006 Date of last inspection Brief Description of the Service: Melbreck is a substantial detached property supporting 26 people who have a learning disability and/or physical disabilities aged between 16 and 65 years. The home is located in a rural area near Farnham. The accommodation has 22 single rooms with two double rooms. There is a large garden with an herb garden, outdoor pool and green house all of which are accessible to service users. The fees charged range from £948.45 to £2370.77 per week. Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection of the service was a surprise visit and was a ‘key inspection’. The inspector arrived at the service at 11.15 a.m. on a weekday. The total number of hours spent at the home was 8 hours. The time spent at the home allowed for a thorough look at how well the service is doing. The inspection took into account detailed information from an Annual Quality Assurance Assessment, completed by the service manager and also took into account information that CSCI has received about the service since the last inspection. We asked for the views of twelve people who live at the home and also asked the views of others who support the needs of the people who use the service via a questionnaire/survey that we sent out. A total of 16 surveys were returned to us, six from the people who live at the home, five from relatives/carers/advocates and five from professionals (care managers, health professional’s and GP’s.). All information received by the Commission for Social Care Inspection since the last inspection, about this service was also taken into account when producing the key inspection report. Staff and the people who live at Melbreck were very welcoming. Discussions with two staff members, the Registered Manager and one individual took place. The majority of people who use the service have communication support needs, therefore observation was also used as a source of information throughout the visit. The inspector looked around the home including the bedrooms of individuals at their invitation. A number of records were viewed including individuals care plans, staff recruitment records, staffing rotas and maintenance/health and safety records. The inspector looked at how well the service was meeting the standards set by the government. The report includes judgements about the standard of the service. The inspector would like to thank the manager and staff team for their assistance with the inspection. Thanks also to the people who use the service, visitors and all others who shared their experience of this home. What the service does well:
Prospective residents are given information that will help them make an informed choice about whether to live at the home. There is a clear and detailed assessment process to ensure that all prospective residents support/care/nursing needs are assessed. The process ensures that the service is able to meet people needs before they move in.
Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 6 Care and support plans are based on detailed assessments of peoples needs and support the good quality care provided by staff. The people who live at the home are also enabled to take risks, in order that they are as independent as possible. The people who live at the home are offered a good diet, in order that nutritional needs are met. Personal and healthcare needs are appropriately supported. Staff continue to provide personal support in ways, which people prefer, in order that their needs are best met. Staff clearly promote individuals’ physical and emotional health, to keep them healthy and well. Access to additional support from health care professionals is consistent and meets health needs. Six people who live at the home responded to a survey and told us that they are happy with the support they receive, adding that they felt that staff know when they are unhappy. Feedback from families was also positive, “ Melbreck is a true ‘home from home’ for our son. He is given excellent care…The staff are always very friendly and caring and happy. Not too much changing of staff either…The home provides a good social life and a wide variety of outings and social events…The home allows us the confidence to know our daughter is in the care of people in whom we have every faith and that our daughter is happy in their care…Our son is encouraged to experience ‘life’ in all it’s many facets, he has an excellent social life.” Needs arising from equality and diversity are well met. From the evidence seen, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. The storage and administration of medication ensures the protection of individuals. Medication practice is well managed at the home, to ensure that health and well-being are promoted. A clear complaints process is available to the people who live at the home and their representatives. There continues to be an effective complaints procedure in place, to listen to the views of individuals. Protection of the people who live at the home is assured by the availability of adult protection guidance, appropriate training and staff awareness. A pleasant and comfortable environment is provided for the people who live at Melbreck. People’s bedrooms reflect individuality. The design and layout of the home, including adaptations and equipment meet individual need. The home is clean and hygienic, continuing to guard against the risks of infection and ill health. Staff are attentive and respectful promoting communication and independence in relation to need and abilities. Competent and qualified staff work at the
Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 7 home. Training provided to staff ensures that they are competent and qualified to meet individual needs. Staff records indicate that the recruitment process ensures the protection of residents. There is regular monitoring by the provider, to ensure that the home is efficiently run and providing good standards of care. Records are generally well-maintained. The manager has a good understanding of the needs of the people who live at Melbreck and has worked for the organisation for a number of years. The manager’s skills and experience are supported by nursing and management qualifications. Staff described the manager as being very supportive and knowledgeable, defining clear boundaries of nursing and support offered at Melbreck. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good Prospective residents and/or their representatives are given information that will help them make an informed choice about whether to live at the home. There is a clear and detailed assessment process to ensure that all prospective residents support/care needs are assessed. The process ensures that the service is able to meet people needs before they move in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A statement of purpose and service user guide are in place, providing prospective residents and their relatives with sufficient information to help them make an informed choice about living in the home. A pre admission needs assessment is completed by the manager for with prospective residents and includes information from relatives and health/social care professionals. The assessments seen by the inspector provided clear information about an individual and their support needs Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 10 People are given the opportunity to visit the home to ensure it is suitable for their support needs. This also provides an opportunity for the people who live at Melbreck to meet the person and play a part in the admission process. Contracts of occupancy continue to be in place, which outline the care provided, the accommodation offered, the fees payable. Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good Support/care plans are in place, which provide clear information as to how people like to be supported. The plans are updated and reviewed to ensure that needs are met in a safe and consistent way. The people who live at the home are supported to make decisions about their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the individual care/support of five people who live at the home. The care/nursing plans (including a health action plan) provide detailed information in relation to a number assessed needs e.g. ‘Care of personal hygiene’, ‘Care of nutrition’, ‘Safe environment’, ‘Socialisation’, ‘Sleep’. The documents provide clear information as to how each person likes to be supported and it was clear that where possible the individuals, their families/representatives and health/social care professionals contributed to the
Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 12 support plan. The information is reviewed on a regular basis to make sure that information is relevant and up to date. Each person also has a ‘My passport’ which describes a person’s support needs but also includes information about how an individual communicates. The passport clearly identifies and guides staff in the interpretation of sound and gesture. For example, “ I cannot verbalise, but I can express my feelings by thumb sucking and rocking in my chair slightly if I am happy and content…If I’m upset, distressed or bored I will become agitated and bit my hands and slap the side of my face or my ear…Please talk to me all the time while assisting with all the usual daily activities. Please speak softly and clearly to reassure me.” The passports include a photo of the person, their name and address, a section called ‘About me’, ‘How I communicate’, ‘If I do this it means’, ‘Helping me with food and drink’, ‘Mobility and physical support’, ‘My hygiene support needs’ and ‘My medication’, providing a clear understanding of who people are. All of the people who live at the home have a key worker who has a good understanding of their needs and will assist people to make basic decisions about. Six people who live at the home responded to a survey and told us that they are happy with the support they receive, adding that they felt that staff know when they are unhappy. Feedback from families was also positive, “ Melbreck is a true ‘home from home’ for our son. He is given excellent care…The staff are always very friendly and caring-and happy. Not too much changing of staff either.” Risk assessments are in place for all identified risks and are included in the care plans. These are reviewed and updated regularly. Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good The arrangements in place for personal development and leisure activities meet the individual and collective needs of the people who live at the home. People are supported to make choices, which meet individual needs. The menu is varied and meets the needs of the people who live at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual time- tables of daily activity continue to be in place for each person. These include activities provided at a day centre, which a number of people attend on selected days. A therapy unit situated at the rear of the property, which is managed by an activities coordinator where some people attend. Activities include drama,
Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 14 music, cookery, art and craft, cookery and relaxation in the “white room”. Individuals continue to access the local community and trips out to local attractions; shopping trips are also organised. Family links are maintained and visitors are encouraged to visit the home at any reasonable time. Families are also encouraged to attend care reviews and participate in care planning. Feedback from families included very positive comments about the support offered at the home, “The home provides a good social life and a wide variety of outings and social events…The home allows us the confidence to know our daughter is in the care of people in whom we have every faith and that our daughter is happy in their care…Our son is encouraged to experience ‘life’ in all it’s many facets, he has an excellent social life.” A local church facilitates a Holy Communion Service in the home on a regular basis, which people can choose to attend. People who may have other beliefs or faith can be supported to attend or receive support from their faith group upon request. The chef is new in post and is currently reviewing the menus with input from the people who live at the home with support from staff. Two main dishes are offered for lunch and the evening meal. Special diets and needs are catered for, supported by a dietician as required. A number of people require support to eat and drink, which was undertaken in a sensitive and caring manner. The kitchen was clean and orderly. The appropriate records required for health, safety and hygiene were in place and well maintained. Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good Personal and healthcare needs are appropriately supported. Staff promote individuals’ physical and emotional health, to keep them healthy and well. Access to additional support from health care professionals meets individuals’ health needs. The storage and administration of medication ensures the protection of the people who live at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Support/care plans guide staff in how people wish their personal and healthcare needs to be supported, ensuring that individual’s health and welfare is maintained as far as possible. The manager and staff have made a clear commitment to ensuring that the plans are reviewed on a regular basis. All of the people who live at the home require full assistance with personal care and when needed this was carried out in private.
Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 16 The manager has ensured that appropriate equipment is available to assist with the individuals’ daily living/care tasks, and staff were seen to be using the equipment appropriately. All the people who live at the home remain registered with a local GP who visits the home every two weeks. People may also visit the GP surgery by appointment. The manager has developed close links with local health care professionals, using every opportunity to ensure that people are receiving appropriate health care support when required. Medication reviews are conducted with the doctor on a regular basis. Records showed that staff are continuing to promote attendance at routine health care appointments. A chiropodist continues to visit the home every six weeks and the optician will provide tests every two years. There is also access to the continence advisor, and the dietician who also advises on nutrition and assisted feeding systems. Dental care/hygiene is provided by a dental practice in Guildford. The organisation employs a physiotherapist who advises on individual physiotherapy programmes, specialist equipment and monitors the use of specialist chairs and seating. The home also has a full time physiotherapy assistant who supports people to carry out the physiotherapy programme relating to their needs. The home has a policy for the administration of medication. All of the people who live at the home require assistance with taking their medication and this is recorded within support plans. We saw how medication was given when we visited the home and found that medication is administered safely. Medication administration is only completed by qualified staff (nurses). Medication is supplied by a local pharmacist mainly in blister pack format and stored in lockable and secure medication trolleys. The medication recording charts are available for each person; no gaps in recording were seen and records are well maintained. All medication entering and leaving the home is recorded to ensure the safety of the people who live at the home. Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good A clear complaints process is available to listen to the views of individuals and their representatives. Protection of the people who live at the home is assured by the availability of adult protection guidance, appropriate training and staff awareness. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No formal complaints have been received at the home or at the CSCI since the last inspection. The home continues to have a complaints procedure in place, which forms part of the service users guide. The people who live at the home and their relatives have access to this procedure. Due to the complex support needs of some people who live at the home the unhappiness of an individual may be recognised through sound and gesture, which are described clearly in individual communication books/profiles. Each person has a communication profile, which identifies and describes how to recognise when someone is unhappy. There is an abuse awareness policy in place and all staff working in the home have undertaken training in this policy during their period of induction. There is also a copy of Surreys Multi Agencies Policies and Procedures on Safeguarding Vulnerable Adults in place, and the manager confirmed that she
Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 18 has enrolled in updating training in these procedures. There are currently two Vulnerable Adults investigations being undertaken, and the home is following the appropriate course of action. The home continues to have whistle blowing and Protection of Vulnerable Adults procedures in place. Staff training records showed training regarding the Protection of Vulnerable Adults is being undertaken. Staff members spoken with were able to provide a good account of how to respond to allegations. Staff members also confirmed that they have been made aware of the whistle blowing policy. Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 & 30 Quality in this outcome area is adequate A clean, homely and comfortable environment is provided. People’s bedrooms reflect individuality. The design and layout of the home, including of adaptations and equipment meet the needs of the people who live at the home. The home is clean and hygienic, continuing to guard against the risks of infection and ill health. External repairs are needed to ensure the safety of the people who live at the home. This judgement has been made using available evidence including a visit to this service. Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 20 EVIDENCE: The home continues to be clean and comfortable. Communal space is available within five lounges and dining rooms, which have been furnished to a good standard. People’s bedrooms are well -decorated to individuals taste, containing personal items, which reflect individual personalities and interests. There are enough toilet and bathrooms situated throughout the home. Toilets and bathrooms are adapted to meet the mobility needs of the people who live at the home. These include overhead hoists, shower trolleys, raised toilet seats and specially adapted toilet surrounds. The home has two shaft lifts and one stair lift to ensure that people are able to access all areas throughout the home. There are ramps in place to access a well-maintained mature garden with a sensory garden, raised flower- beds, and patio areas. The main driveway of the home has a number of pot-holes and does not ensure safe access for the people who live at the home or safe access for visitors. Following the inspection the provider has stated that the driveway at the front of the home is not used by the people who live at the home as a safe entrance as suitable surfacing is made available at the side of the home through another driveway and separate entrance. The provider has agreed that a review/action will be taken as necessary to make sure the potholes are attended to. The home is clean and hygienic. The carpets on the first floor corridor remain stained but are due to be replaced in the near future. The laundry is well equipped and arrangements are in place for the weekly collection of clinical waste. Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good There are sufficient numbers of staff to support the needs of the people who live at the home. Competent and qualified staff work at the home. Staff employment records indicate that the recruitment process ensures the protection of the people who live at the home. Staff training and qualifications support the needs of the people who live at the home. Training provided to staff ensures that they are competent and qualified to meet individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager, two nurses, five support/care and the chef were on duty at the time of the inspection. The staff duty rota and the number and skill mix of staff ensured that the assessed needs of individuals could be met. The nursing and support staff have worked at the home for some time and know the care and support needs of people who live at Melbreck. No agency staff were being used at the home at the time of the visit.
Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 22 We had the opportunity to speak with three members of staff to explore their knowledge of supporting individuals. The staff members were able to describe a sound knowledge of the needs of the people who live at the home, had a clear understanding of care needs and the importance of promoting choice and individuality. Staff recruitment procedures remain at a good standard. Five staff recruitment files were seen and all contained information to ensure the protection of the people who live at the home i.e. application form, two written references and a CRB (Criminal Records Bureau) disclosure reference number. Staff records indicate that a number of staff have been employed at the home for numerous years, providing continuity to the people who live at Melbreck. Staff confirmed that they complete induction training and are given two weeks at the beginning of their employment to “get to know people and have an understanding of their needs”. Records showed and several staff confirmed that they are offered training relating to the needs of the people who live at Melbreck, which includes, manual handling, intensive interaction, safeguarding people and epilepsy awareness. Other training offered includes food hygiene, fire safety, and COSHH. Records confirmed that the staff group have a mix of skills and knowledge to support individuals’ needs. NVQ training is ongoing with sixteen staff holding an NVQ level 2 or above (75 ) and two staff currently undertaking this training, this is higher than the minimum standard of 50 . The manager remains an NVQ Assessor and an Internal Verifier providing ongoing support to staff to obtain the qualification. Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good The home is well managed and staff work as team, which benefits household members. The organisation has systems in place to monitor the quality of care and to ensure that standards are being maintained. Health and safety practices safeguard the people who live at Melbreck This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has a good understanding of the needs of the people who live at Melbreck and has worked for the organisation for a number of years. The manager’s skills and experience are supported by nursing and management
Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 24 qualifications. Nursing and management within the home is supported by a team of qualified nurses ensuring the home is appropriately managed at all times with an on call system in place. Staff described the manager as being very supportive and knowledgeable, defining clear boundaries of nursing and support offered at Melbreck. Regular visits to the home are completed by the provider to look at the quality of care/support. Reports of these visits are held at the home. The people who live at Melbreck are supported by their relatives to complete a questionnaire, giving them the opportunity to “have their say” about how they are supported at the home and whether their needs are met. Health and safety is promoted and all staff have regular training in COSHH procedures. The manager confirmed that safety checks and records held in relation to health and safety are accurate and up to date. The fire log showed that routine tests are carried out and that maintenance and servicing takes place. Additionally a fire based risk assessment was in place. Staff receive fire safety training every year. Generic and individual risk assessments are in place for all identified risks, inclusive of safe working practice. The procedure for recording and reporting of incidents and accidents remains satisfactory. Melbreck DS0000017623.V347694.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 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 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 4 X 3 X X 3 X Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 YA24 Regulation 23:2 (o) Requirement The registered person must repair the pot holes in the driveway to ensure safe access for the people who live at the home and safe access for visitors. Timescale for action 29/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Melbreck DS0000017623.V347694.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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