Inspection on 12/05/06 for Moss Cottage

This inspection was carried out on 12th May 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Moss Cottage 31/01/06

Moss Cottage 21/10/05

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 Moss Cottage 7 Western Road Liss Hampshire GU33 7AG Lead Inspector Marilyn Lewis Unannounced Inspection 12th May 2006 10:00 Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 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 Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 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. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Moss Cottage Address 7 Western Road Liss Hampshire GU33 7AG 01730 894 242 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.c-i-c.co.uk. Community Integrated Care To Be Confirmed Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 Brief Description of the Service: Moss Cottage is a small residential service providing care and support to four adults with a learning disability. Community Integrated Care provides the care and support and the building is owned by the health authority who are responsible for the maintenance of the property. Service users are accommodated in single rooms, one of which is on the ground floor and there is a lounge, kitchen/dining room, a bathroom and shower room. There is an office, which is also used as a sleep over room, on the first floor. The gardens are to the rear of the property. The home is located in a residential street and is indistinguishable from the other houses in the street. Cars are currently parked on the road outside the home. Discussions are taking place, to provide parking space at the rear of the property, for the two vehicles used by service users. The home is close to the shops and railway station in the small village of Liss which is in a rural part of Hampshire. The manager stated on the 12th May 2005, that fees ranged from £62.35 to £94.45 a week. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 12th May 2006. The four service users were out and about during the day, but met with the inspector when they were at home during the visit. Care plans were assessed for all the service users and a selection of records were seen, including medication records and staff recruitment and training records. The inspector spoke with the manager and two members of staff and toured the home, at one time accompanied by a service user. What the service does well: What has improved since the last inspection? The home now provides service users and their relatives with a Statement of Purpose and Service User Guide that give clear information about life at the home. Care needs assessments have been undertaken and now form the basis for the individual care plans that provide staff with the information they require to meet the needs of the service users. Risks assessments have also improved but require further development to ensure all risks have been identified for daily living and leisure activities. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 6 A training programme is in place for staff at the home that includes training in the administration of medicines and abuse awareness. The manager must ensure staff complete the training workbooks that have recently been allocated to staff. Service users and their relatives have the opportunity to give their opinions on the quality of care provided. At the time of the last inspection service users were not receiving their personal allowances. On this visit records seen indicated that service users were now in receipt of their allowances. 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. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 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 Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Service users and their relatives have the information they require about life at the home and care needs assessments are being developed to ensure the home can meet the service users needs. EVIDENCE: Since the last inspection the home’s Statement of Purpose has been reviewed and now provides service users with clear information about life at the home, including the age range of service users, support offered to observe cultural and religious practices and how service users will be consulted about the running of the home. A Service User Guide has been developed and a copy has been given to each service user. The document provides information on all aspects of life at the home. Copies seen were in a written format. The manager said that the information was also available on tape for service users who found it easier to understand when spoken. All the service users have lived at the home for a number of years and assessments of their care needs on admission were not available. Staff have been working to develop care needs assessments for each service user and these were seen during the inspection visit. The assessments covered the service user’s care needs including personal and social care. Each service user has a written contract giving them the terms and conditions for living at the home. The contract states the fees to be paid and lists services Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 9 that are available at additional costs such as hairdressing and the purchase of toiletries and clothing. Rooms in the home are not numbered, so room numbers had not been included in the contracts. The manager said that the number of each room could be identified by the plan of the home and the appropriate number would be added to the contract. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 10 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, 8 and 9 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Care planning has improved and care plans have been developed that provide staff with the information required to support the service users. Service users are supported to make their own decisions about daily living activities. However risk assessments require further development to ensure all the risks for daily living and leisure activities have been identified. EVIDENCE: Since the last inspection care plans have been developed for each service user. The four plans seen gave information on the needs of the service users and the actions required to meet those needs. Areas covered included communication, personal hygiene, health, working and recreation and sleeping. The plans had only been developed over the last month and so had not yet been reviewed. A service user spoken with knew about the care plan but there was no evidence that service users or their relatives had been involved with the development of the plans. The manager said that he would arrange for service users or their relatives to be involved during the review of the plans. It was evident during the visit that service users were able to make decisions about their daily lives. Each service user was involved in a different activity Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 11 during the day with one attending a day centre, one going to visit relatives and then shopping for clothes for a forthcoming holiday and two were out for drives. All the service users looked relaxed and happy. The service user who was due to go shopping said that they were looking forward to the holiday and was excited about going to buy new clothes for the trip. Care plans seen indicated that service users were encouraged to be as independent as possible and staff were observed supporting service users in a sensitive manner while getting snacks in the kitchen and choosing clothes to wear on trips out. One care plan seen indicated that service users wishes were included in the planning of their lives. A service user wished to work in a charity shop and arrangements had been made for time to be spent at the shop and at a day centre where the service user is gaining experience by helping staff with teas. There is now a possibility that the service user may be able to help at a shop in the local village. The manager said that three staff members were due to attend training in Person Centred Planning which would give them the skills to develop the care plans further to include the goals and wishes of service users to a greater extent. Risk assessments have also improved since the last inspection. Risk assessments were seen for daily living activities for each service user, including risks when eating and drinking and going out into the community. Discussion took place with the manager and senior support worker about developing some of the assessments further, such as a risk assessment for a service user with epilepsy did not indicate the risk could be minimised by ensuring the correct medication was given. A risk assessment for bathing was also required for this person as staff allow the service user privacy while in the bathroom but must wait at the door in case assistance is required. Staff at the home at the time of the visit were aware of this procedure but any new staff members would not be. Although risk assessments were dated they also need to be signed by the person undertaking the assessments. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 12 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): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Service users are able to maintain contact with family and friends, participate in suitable leisure activities and are part of the community. Service users enjoy balanced and varied meals served in a relaxed atmosphere. EVIDENCE: Daily records seen for service users indicated that they were involved in many suitable leisure activities and were able to be part of the community. Activities included trips out to places of interest such as Portsmouth, The Isle of Wight and Hayling Island. A service user going out on a trip on the day of the visit said that outings to the coast were ‘good’. Social events such as barbecues were held at the home and records seen indicated that relatives and friends were able to join service users at these events. A service user visits relatives twice a month and the other service users also see relatives but no so frequently. The records stated that one service user met with a friend for coffee in a local coffee shop and the service users belong to a social club that is held monthly in Petersfield. The records indicated that service users were able to choose Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 13 whether or not to participate in the activities and it was evident during the visit that they were able to decide when they would go out and when they would spend time alone in their rooms. Two service users spoken with said that they were able to decide for themselves what they wanted to do. Daily records for two service users who are particular friends, indicated that they went out for lunch together once a fortnight. During the visit a service user spoke with the inspector about the excitement of preparing for a holiday. One service user attends a day centre four days a week. He returned to the home during the inspection visit and when asked by a staff member if he had enjoyed his time at the centre, indicated that he had. Currently there are no service users living in the home who are from different ethnic groups. The manager said that the service users had not indicated any wish to attend religious services but if they did, staff would arrange to support them in attending. During the visit staff were seen to interact with service users in a friendly, caring and respectful manner. Service users spoken with said that staff were ‘kind and friendly’. Each service user had a locked container or drawer for personal items and were able to have a key to their room if they wished. The manager said that at present the service users did not want keys to their rooms and it was agreed that this would be recorded in their care plans. A service user confirmed that they did not wish a room key. It was evident during the visit that service users were relaxed when preparing and eating meals in the dining area of the kitchen. Service users were seen to help themselves to snacks including toast and fruit during the morning of the visit. Weekly menus are drawn up following consultation with the service users and some of them go with staff to purchase the groceries. The menus indicated that meals offered were varied and gave choice. One service user likes to have a separate menu of items he has chosen. Two service users said that they enjoyed the meals provided. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 14 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 and 20 Quality in this outcome area is good. The judgement was made using available evidence including a visit to the service. Service users are treated with respect and receive personal care in the manner they prefer. Service users health care needs are met and they are protected by the home’s procedures for handling medicines. However the lack of a risk assessment for the self-administration of medicines could put one service user at risk. Staff must complete training in the administration of medicines to minimise the risk of errors when giving service users their medication. EVIDENCE: Care plans seen provided information on the service users preferences for receiving personal care for example when showering or bathing. Also included were details such as which toothpaste was preferred. The care plans indicated that service users were able to do as much for themselves as possible to maintain their independence and to give privacy as required. Daily records seen indicated that service users health care needs were being met. Each service user is registered with a GP practice and visit when required. Staff had recently contacted the GP on call services for one service user who had been ill and the service user had received a home visit. A consultant psychiatrist also visited Service users every six months and their current medication was reviewed at this time or more frequently if required. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 15 Regular check ups at the dentist were also recorded and visits by a nurse specialising in the care of epilepsy were also documented. The home has procedures in place for receiving medicines into the home and for disposing of any unwanted items. Medication records seen had been completed appropriately and medicines were stored securely. One service user administers his own medication and this is recorded in his care plans. However a risk assessment is required for the self-administration of medicines. At the time of the last inspection it was noted that staff had not received training in the administration of medicines. During the last week a workbook produced by the organisation has been given to staff members as a training tool in handling medicines. These have not yet been returned for assessment. Following discussion on the possibility of having an external competent person to provide additional training the manager said that he would discuss this further with his line manager. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 16 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 and 23 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. Service users know how to make a complaint and feel that staff will act to resolve the issue. Service users finances are protected by the home’s handling of their personal finances. Staff have not yet completed training in abuse awareness and do not have all the documents available to inform them of the procedures to be followed should abuse be suspected. EVIDENCE: The home has a complaints procedure in place that indicates who will investigate the complaint and timescales for the process. Records seen indicated that complaints were taken seriously and acted upon quickly. A service user spoken with knew what to do if unhappy with something at the home and they said that a staff member would ‘sort it out’ At the time of the last inspection service users were not receiving their personal allowances, as there was a delay with the organisation’s head quarters making payments into their individual accounts. On this occasion bank details seen indicated that the service users were receiving their personal allowances on a regular basis. Small amounts of service users money were kept at the home. The monies were stored securely in individual containers and receipts were kept for all transactions. Records seen for two service users matched the amount of money held. The home has copies of the organisation’s abuse procedures but still does not have a copy of Hampshire County Council’s policies for the Protection of Vulnerable Adults. During the last two inspections the manager has been asked to provide this document for staff as it forms the basis for the protection of Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 17 vulnerable adults in Hampshire. A requirement has been made at this inspection for the document to be made available to staff. It was a requirement of the last inspection that staff receive training in abuse issues. Staff have recently been given a workbook as training in abuse issues but no date has been set for the work to be completed. Discussion took place as to whether this form of training was sufficient and the manager stated that staff might benefit from attending a group session with discussion on abuse issues and that he would look at additional group training. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 18 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, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. Service users live in a clean and homely environment but could be at risk by the lack of risk assessments for the gas fire in the lounge and the lack of a call alarm system for the service user accommodated in a room on the ground floor. EVIDENCE: At the time of the visit the home looked clean and homely. Service users rooms contained many personal items and two service users spoken with said that they liked their rooms and had chosen the colours for the décor themselves. One service user has a ground floor room to enable independence of movement when using a wheelchair. The home has a bathroom with toilet; a shower room with toilet and all the service users rooms have a wash hand basin. Service users also have access to the lounge and kitchen and dining area. A gas fire in the lounge did not have an additional guard around it to ensure injuries would not occur if a service user was to go near to the fire or trip and fall against it. The manager said that the fire was rarely used, as the home was warm from the central heating system. The manager is to risk assess the use of the fire. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 19 A call alarm system is not in use in the home and this was cause for concern for the service user who had a room on the ground floor. At night the staff member on duty is a ‘sleep’ staff member and following the last checks at around 11pm or when ever the last service user has gone to bed, the staff member goes to bed in the sleep over room on the first floor. The manager said that he would arrange for some form of call alarm to be set up in the ground floor room so that the service user could summon help if he required it at night. A risk assessment is also required for the service user being alone downstairs at night. The manager could not locate the risk assessment for the buildings and gardens. This will be looked at during the next visit to the home. The garden to the rear of the property has seating provided and there is space for service users to hold barbecues. A gardener has recently been employed to maintain the garden. Service users spoken with enjoyed spending time in the garden. An access lane runs alongside the garden and discussions are taking place to provide parking in the garden for the home’s two vehicles. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 20 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 AND 36 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. Staffing levels are flexible to meet the needs of the service users and staff are able to gain National Vocational Qualifications. Improvements in the training programme for staff must continue if they are to fully support the service users. Service users safety could be put at risk by the lack of robust recruitment procedures. EVIDENCE: The home employs the manager, a senior support worker who is the deputy manager and five support workers. Two of the staff members hold National Vocational Qualifications (NVQ) level 2 or above and two are due to start studying for the award. The manager holds NVQ level 3. A minimum of two staff members are on duty for each shift during the day and evening and one staff member ‘sleeps’ in at night. On the day of the inspection visit three staff members plus the manager were on duty. The manager said that staffing levels were flexible to allow service users to go on trips out and to participate in leisure activities. A service user spoken with said that staff came quickly if help was required. Recruitment records were seen for two staff members who had commenced work in the home during the last six months. One of the records did not contain any proof of identity but did have two written references and checks from the Criminal Records Bureau and Protection of Vulnerable Adults. Records Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 21 seen for the second person contained proof of identity but did not contain any references. This person had transferred to the current organisation from the previous organisation and when the manager checked with the Human Resources department he was told that it was not the policy or the organisation to take up references for staff transferring over. The files for staff members who transferred over were not passed on by the previous provider. This must be documented in the files of staff affected in this way. Training records seen indicated that improvements have been made in this area since the last inspection. Six of the seven staff members have received training in food hygiene and all have received first aid training. Six staff members have also attended training in moving and handling. The deputy manager has received training as a moving and handling facilitator and is arranging for refresher courses for staff as required. Four staff members had attended training in epilepsy care prior to joining the current organisation. Although records for one service user states that the person uses Makaton as a form of communication, no staff members have received training in this. The manager showed the inspector confirmation of a booking for a trainer to attend the next staff meeting to discuss this training. The manager is also looking at programmes for training staff in learning disabilities. A check on the progress of staff training in this topic will be included in the next inspection visit. Records seen indicated that staff are receiving regular supervision from the manager or the deputy manager. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 22 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, 38, 39 and 42 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. The manager and deputy manager work together to ensure the home runs smoothly. Service users and their relatives have the opportunity to give their opinions on the quality of care provided but the home must ensure a system is in place to provide feedback on the information gained. The safe working practices in operation in the home protects the health, safety and welfare of service users. EVIDENCE: The manager has recently registered with the commission. Mr Joe Snowden is managing Moss Cottage plus another small home run by the organisation in Petersfield. Each home has a senior support worker who is the deputy manager of the home and they cover when the manager is away from the establishments. The manager is also undertaking the Registered Managers Award and training through the organisation so time at each home is limited. It was evident during the inspection that time between the homes was shared as Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 23 there was an occasion when the manager had to attend to an issue in the other home during the inspection visit. The deputy manager took over the running of the home in his absence. One service user was at home during this time and was not inconvenienced by the manager’s absence. It was evident during the inspection that the manager and deputy manager worked together to ensure the smooth running of the home. At the time of the last inspection a requirement was made for a system of reviews to be put in place to obtain the views of the service users and their relatives on the quality of care provided at the home. A survey had been introduced at a staff meeting held the previous week and staff were due to work alongside service users to obtain their views in the coming month. Surveys had also been recently posted to relatives and had not yet been returned. The manager said that one service user had very frequent visits to parents and at these times staff took the opportunity to talk with them and seek their views on the care provided. Relatives also had the opportunity to voice their opinions during social events held at the home. Discussions took place as to how the outcomes of the surveys would be fed back to the people who had taken part to ensure they were aware of the outcomes and any actions to be taken to resolve any issues that had been raised. Staff meetings have been organised and are usually held on a monthly basis. Records seen for the meetings indicated that a wide range of topics were discussed including health and safety issues, service user care and staff training. Records seen indicated that regular checks are carried out on the fire alarm system although the manager stated that a confirmation certificate for the last checks undertaken on the fire safety equipment had not yet been supplied by the company who had carried out the tests. The manager was to obtain this. Staff receive training in fire safety during their initial induction and an annual visit from the fire service was being arranged. All staff had attended the last fire drill, which had taken place during a staff meeting. The manager said that although staff were attending a staff meeting they were unaware that a fire drill was to take place. Discussions took place about holding fire drills at different times of the day to ensure staff felt confident about the procedures when only a few people were on duty. Set procedures are documented for the possibility of a fire taking place at night when only one member of staff is on duty. Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 2 36 3 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 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 2 x x 3 x Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 25 YES 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 The registered person must ensure care plans are developed and reviewed in consultation with the service user or their relative or representative. The registered person must ensure staff have all the information required to protect service users from abuse, including Hampshire County Council’s procedures for the Protection of Vulnerable Adults. The registered person must ensure proof of identity is obtained for all staff employed at the home. This is an outstanding requirement of the inspection report dated 31/01/06 The registered person must ensure that a risk assessment is undertaken with regard to the use of the gas fire in the lounge. Timescale for action 31/07/06 2. YA23 13(6) 31/07/06 3. YA34 19 31/07/06 4. YA24 13 (4)(a) 31/07/06 Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 26 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 Moss Cottage DS0000064988.V292215.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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