Inspection on 06/07/06 for Nairn Close - Orkney Close

This inspection was carried out on 6th July 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nairn Close - Orkney Close 12/09/05

Nairn Close - Orkney Close 06/04/05

Nairn Close - Orkney Close 17/11/04

Nairn Close - Orkney Close 20/04/04

Nairn Close - Orkney Close 05/03/04

Nairn Close - Orkney Close 13/10/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Fch - Nairn Close/Orkney Close 2 Nairn Close Nuneaton Warwickshire CV10 7LG Lead Inspector Sheila Briddick Key Unannounced Inspection 6th July 2006 08:45 Fch - Nairn Close/Orkney Close DS0000004360.V300344.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 Fch - Nairn Close/Orkney Close DS0000004360.V300344.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. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fch - Nairn Close/Orkney Close Address 2 Nairn Close Nuneaton Warwickshire CV10 7LG 02476 353399 02476 344357 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) FCH - Housing and Care Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2005 Brief Description of the Service: 2 Nairn Close and 9 Orkney Close are part of FCH Friendship Housing and Care. The home provides two separate living environments each for three people with a learning disability. The houses are in close proximity to each other and function as two separate units although staff work across both houses. Each house provides service users with single bedroom accommodation, a bathroom and toilet facility, lounge, kitchen and dining room. A downstairs bedroom facility is available at each house, which at 9 Orkney Close includes an ensuite shower and toilet facility. There is also a conservatory at 9 Orkney Close. There is limited but sufficient parking to the front of each house with enclosed gardens and patio areas to the rear. The properties are in an established residential area of the town of Nuneaton, close to local shops and on a bus route to the town centre. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. This unannounced inspection took place over one day and commenced at 8.45 am on Thursday July 6, 2006 and finishing at 3.15pm. The inspection involved: • • Discussions with the Manager and care workers on duty at the time. Two service users were identified for close examination by reading their, care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for residents. A tour of the environment was undertaken, and records were sampled, including staff training, health and safety, rotas and fire records. Interactions between service users and staff were observed. Informal discussion with two service users met with during the visit. • • • Finally, feedback took place with the Manager and Care Manager about the inspection findings. What the service does well: Significant time and effort is spent making admissions to the home personal and well managed. New people coming to the live in the home are given opportunity to spend time there and other service users views are sought on the compatibility of the person coming to live with them. The home has a strong ethos of involving residents in all aspects of their life with all service users having a good care plan that reflects their individual needs and choices. The service is to be particularly commended for the good practice they are developing in supporting service users to own their care plan reviews and in the positive way they are recording everyday activities of service users. Service users have a choice over their personal care and are being encouraged to be independent. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 6 The atmosphere in both houses was very relaxed and service users were obviously very comfortable with the people supporting them. Routines in the home are planned around service users needs and wishes and the staff team demonstrated a commitment to being flexible to meet individual wishes and supporting service users to achieve their personal goals. 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. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have sufficient information they would need to choose a home, which will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: Since the last inspection visit a new service user has come to live in the home and an examination of all records relating to the admission took place. It was found that a full assessment had been undertaken through the care management assessment process and the home was currently developing a care plan based on this assessment. Referrals had been made to speech and language therapy services to support the care planning process. There was significant evidence to show that the service user had been able to visit the home on several occasions prior to coming to live there and these visits included overnight stays. The records relating to visits were good and clearly demonstrated the support given to the service user to make a decision about living there. Service users already living in the home had opportunity to discuss the compatibility of the new person and a record of this discussion is on their house meeting minutes. Service users spoken with said that they liked the new person and they felt they had settled into the home well. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear, consistent care planning system in place to provide staff with the information they need to satisfactorily meet service user needs. The people living in this home are supported to take responsible risks based on effective risk management strategies that are agreed and recorded on the individuals care plan. EVIDENCE: Two care plans were ‘case tracked’ as part of this inspection visit, both of the service user’s whose care was being case tracked were met with during the visit. One of the service users was able to communicate verbally and expressed satisfaction with their lifestyle and their views are included in this report. The other service user appeared happy and relaxed in their home and with the person supporting them. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 10 Information on their care plans was up-to-date and generally in good order. There is a new manager to the home who is currently reviewing the care plan format and a completed one was examined. The new format clearly identifies a service user’s goal, the reason for the goal and the plan of action necessary to support the service user to achieve the goal. A monthly summary sheet is completed to cover any review progress in all areas of need. The service is working closely with behavioural therapists, speech and language services and community nurses in the development of care plans and monitoring records are maintained as requested by specialist services during the assessment process. Risks are known during the assessment process however the risk assessment is not always recorded until the outcome of the assessment process and strategies to minimise any risk are agreed through discussion with the specialist services. The manager agreed that interim risk assessments should be in place to be sure that service users and staff were protected from harm until the assessment process is complete. Risk management in this home continues to be good however with risks for each individual identified and recorded on the care plan. This includes risks in activities in the home, when out in the community, regarding financial management and use of equipment. Care plans are being reviewed on a regular basis and development in care plan reviewing includes supporting the service user appropriately to own the review meeting. This good practice includes promoting terminology to be more positive, using photographs, which is meaningful to the service user, and involving the service user in preparing for the review. A record in a service users diary noted, XX went to the office today with a key worker to plan the review meeting, printed photographs to use at the review of their activities since the last review. There is ongoing development in this service to enable service users to make decisions about their lives with appropriate support and assistance. This includes holding regular house meetings and a new way of doing this has recently been introduced with two staff taking the lead. A photographic record is made of the agenda, for example a photograph of the fire alarm if the fire procedure is to be discussed and a photograph of food if the menu is being discussed. Photographs are also taken of the meeting recording service users involvement; the record is purely service user lead. The event is a very social occasion for service users with nibbles and drinks specially purchased for the occasion. The record of the house meeting is available in the dining room so it can be accessed at any time. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home have appropriate support to live ordinary and meaningful lives and to participate in and contribute to the community in which they live. EVIDENCE: There is significant evidence in care plan records, diary records and photographic records of people are having opportunity for personal development and access to a wide variety of activities in the community and for leisure. This includes attending a day service of their choice, local colleges, swimming and keep fit, bowling, eating out and going to the cinema. The service has recently introduced a system for evaluating activities that can be used as part of reviewing individual needs. It was pleasing to note on going development in the recording of daily activities in diary records, this includes recording the outcome of the activity Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 12 for service users and more description of the activity for example, recording that a service user seemed to want their own space today, demonstrating how independence is promoted when service users make their bed or are bathing and dressing, recording how privacy and choice is being respected. Language used in diaries is promoting the services philosophy of providing an ordinary style of living, for example; Packed lunch and went to the kennels to help, went swimming and then Keep Fit. Walked home with friends, freshened up and went to bed 10:30 p.m. Service users are being supported to enjoy their personal interests and this includes photography, and sport. Key workers spoken with were well aware of the individual interests of service users and were actively involved in supporting them to meet goals. A service users spoken with said I like horse racing, I have been to see it on holiday and I like watching it on television. I enjoy watching TV and I watched the football last night. Staff spoken with felt that providing a variety of activities was something they did well, they also felt they provided a relaxed atmosphere in the home without it being boring. Food provision in the home continues to be good. Service users are offered a choice and involved in menu planning. Individual choices are available and likes and dislikes recorded on care plans. Examples of menus viewed were well balanced and nutritious. Care plan records show that the service is working closely with dieticians in care planning to meet specific dietary needs. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected 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. This judgement has been made using available evidence including a visit to this service. Personal support in this home is offered in such a way as to promote service user privacy, dignity and independence. The healthcare needs of the people living in this home are assessed and recognised with evidence of specialist services being readily available to them. Medication is being administered by trained staff. EVIDENCE: This personal support service users prefer and require is recorded on their care plan, this includes, moving and transferring, preferred guidance and support regarding personal hygiene and when choosing their clothes, hairstyle and makeup. Care plans and diaries show that times for getting up and going to bed, having meals and other activities are flexible to meet individual needs. Service users met during the visit appeared well and were dressed smartly. Care practice during the visit was good, promoted independence, was respectful, and offered at a pace and level to the individuals understanding. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 14 The preferred gender care needs of service users is known and where possible this is provided. There are policies in place for moving and handling, sexuality and values however these have not been reviewed since 1998 to ensure that care practice remains in line with changing legislation, for example Valuing People and No Secrets. Care plans seen at this visit demonstrate that health-care needs are assessed and recognised and specialist health care facilities are offering appropriate support when necessary. This includes dentists, opticians, chiropodists, community nurses and psychology services. Care plan programs and risk assessments are in place for specific needs regarding epilepsy are skincare, continence and diet. Staff spoken with said that they felt they had sufficient skills to meet specific needs, including healthy eating and epilepsy management, although would find a specific training in autism useful for supporting service users with this condition. Training records show that this has been arranged for all staff. Staff spoken with demonstrated an understanding of the importance of working with specialist services to meet needs. Personal diaries show that service users are being encouraged to live a healthy lifestyle through diet and exercise. Service users are members of a local keep fit group and one service user is actively involved in the Special Olympics program. Medicine management continues to be to a good standard. The storage, administration and recording of medicines were looked at. This found that all records are completed as required with no errors being evident. All staff administering medicine have been trained to do so and the manager assesses ongoing competency of staff through observation. Service users, where possible, are giving their consent to medicines and this is signed and witnessed by a family member or advocate. A good practice recommendation is made that the relationship of the witness to the service user is also recorded. It was noted that any medication to be given as required is recorded appropriately when administered however a record of creams or ointments prescribed as necessary is not recorded. The medicine cabinet was in good order with medicines stored securely and safely. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected 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 good. This judgement has been made using available evidence including a visit to this service. Robust procedures are in place to protect people from harm, including whistle blowing, and service users can be sure that any concerns will be acted upon. EVIDENCE: There are processes in place for service users to express their concerns and make a complaint if they wish to do so. This can be at their monthly house meeting or through the complaints process and a copy of this is available to them in printed and symbol format. Diary records show that when service users have a concern between themselves appropriate action is taking place to resolve their issues. This may involve seeking support from specialist services. The communication needs of service users are known and care practice observed demonstrated that staff had a good knowledge and understanding of how people communicated their wishes and choices. Policies and procedures are in place for protecting people from harm and this includes a whistle blowing policy. Staff develop a knowledge and awareness of vulnerable adult issues through attendance at Learning Disability Award Framework during their induction and also access specific training in the Protection of Vulnerable Adult Policies and Procedures (POVA). Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 16 There is evidence in care planning that the service works closely with psychology services in the development of care plan programs and strategies for keeping people safe. Care practice observed was promoting service users independence regarding their money with service users being encouraged to take responsibility for small amounts to be spent during the day when they are away from the home. There are policies and procedures in place for the management of service users money and this is recorded on their care plan. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is appropriate for service users particular lifestyle and needs and accessible to community facilities and services. Improvement to bedroom facilities would provide the people living in the home with a comfortable, bright and homely personal space. EVIDENCE: The standard of all shared facilities at both Nairn Close and Orkney Drive is good. The furniture and fittings in these areas is being maintained well and providing service users with an attractive and homely place in which to live. Both houses were bright and cheerful and the people living there appeared relaxed and happy in their environment and were observed to be able to freely access all areas. Diaries and house meeting records show that service users of are involved in decision-making of all issues relating to the environment, for example, choosing furniture and colours for any decorating that is planned. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 18 The gardens at both properties are much improved being bright and colourful with flowers. Service users are encouraged to participate in gardening activities and to buy equipment and garden ornaments if they wish. House meeting records, (through photography), show service users enjoying gardening activities. Staff spoken with have plans for the ongoing development of garden areas at Nairn Close. The carpet in the dining room and on the staircase at Orkney Close have been replaced, with the new flooring in the dining room being of a wood effect linoleum which is more appropriate for a dining area. New kitchen units have been ordered for Nairn Close although the timescale for this refurbishment is yet to be identified. Service user bedrooms although comfortable and clean, are in need of redecorating as wallpaper is torn in places and colours of bed linen, curtains and paintwork do not coordinate. The manager spoke of plans to involve service users in planning colour schemes and choosing fabrics and furnishings for their rooms. The standard of cleanliness in both houses was good and staff demonstrated a commitment to maintaining a pleasant and clean place for people to live. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well-trained, and enthusiastic staff team who work towards common goals. The recruitment policy and procedure for this home ensures that service users are supported and protected from harm by the people caring for them. EVIDENCE: Care practice observed throughout this inspection and discussion with individual staff members demonstrated that staff are good listeners and communicators, interested, and committed to supporting service users to live meaningful lifestyles. Staff spoken with felt they had sufficient knowledge of the disabilities and specific conditions of service users although did feel that more awareness of autism would promote a better understanding of service users needs. Care records and diaries evidence effective working relationships between other professionals and the staff team and this includes psychologists, speech and language services and learning disability nurses. These services are also supporting staff to develop skills in communication and keeping people safe when supporting them. There is a training and development plan for the home and future training planned includes LDAF the new starters, NVQ 2, 3 and 4, autism awareness Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 20 and medication training for new staff. Staff spoken with had discussed their training needs with the manager and had completed NVQ at Level 2 and Learning Disability Award Framework (LDAF). The records for three new staff were examined and found to be up-to-date, in good order and demonstrated that appropriate checks, including Criminal Record Bureau (CRB) and obtaining two references before making an appointment had taken place. Recruitment takes place at the central offices of Friendship Care and Housing with managers of the services being involved in the interview process. All documentation received as part of the recruitment is forwarded to the home manager on completion and this includes a copy of the CRB certificate number. The home manager does not always see a copy of the certificate and may not be aware of any disclosure identified on the certificate. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies and procedures for safe working practice in this home is ensuring that service user health, safety and welfare is being promoted and protected. The manager is supported well by senior staff and is developing strategies for enabling service users and staff to voice concerns and to affect the way in which the services delivered. EVIDENCE: A new manager is being appointed to run the home and an application for the appointed person to be the registered manager is currently being completed and will be forwarded to the Commission for approval for registration. The manager has significant experience of working with people with learning disability and has been the designated a registered manager for two services previously. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 22 The manager is currently reviewing many processes in this service as part of the ongoing development of the service and this is including reviewing policies and procedures. Friendship Care and Housing (FCH) have a number of policies and procedures that have not been reviewed since 1998, as mentioned previously in this report this includes food and nutrition, first aid, moving and handling, sexuality and values, the fire safety policy has not been reviewed since 2000. It necessary for these policies to be reviewed to ensure that they are in line with current legislation and recommended good practice. The manager has recently reviewed the policy and guidance for clinical waste disposal in the home and introduced new measures for it’s safe disposal. The manager is currently looking at developing a service user questionnaire to be used as part of the quality assurance within the service and it is hoped that advocacy support for service users will be accessed as part of the process, this may be from service users day services staff. Development of quality assurance systems has not been ongoing due to management changes that have taken place over the past 12 months and the current manager discussed her intentions for future development. Health and safety management is good and includes ensuring safe working practices through training of staff in moving and handling, fire safety, first aid, food hygiene and infection control. There are systems in place for the safe storage and disposal of hazardous substances, regular maintenance of central heating systems and equipment used in the home and the monitoring of hot water temperatures and control of the risk of legionella. Risk assessments are completed for the maintenance of a safe environment and security of the premises. All accidents, injuries and incidents of illness are recorded and reported to the Commission. Necessary action to minimise any risk following accidents and injuries is implemented and monitored. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 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 3 25 2 26 X 27 X 28 X 29 X 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 2 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X 2 3 X Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 24 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 YA9 Regulation 13.4(b) Requirement Timescale for action 09/07/06 2. YA25 3. YA37 4. YA41 The registered person shall ensure that all activities in which service users participate are so far as reasonably practicable and free from avoidable risk. This includes the interim period whilst an assessment is taking place by specialist services. 23.2(b)(d) Redecoration of service user’s 30/09/06 bedrooms at Nairn Close must take place and linen and fabrics purchased to complement and coordinate the decoration that has taken place. 9.1 The manager for the home, 30/07/06 Maxine Foreman, must forward an application to the Commission for Social Care Inspection to be the registered manager of the service. 12.1 The registered provider must 30/09/06 (a)(b) review the following policies and procedures to ensure that they are in line with current good practice and changing legislation. • food and nutrition. • first aid. • moving and handling. • sexuality and values. • fire safety. Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 25 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 YA9 Good Practice Recommendations It is recommended that were a service users consent to their financial management or administration of medicine has been witnessed by another person the designation of this witness in relationship to the service user be recorded. It is recommended that when any creams or ointments are administered as required a record be made of the time and date on the MAR record sheet. It is recommended that the manager for the home is informed of any disclosure identified on a Criminal Record Bureau certificate. It is recommended that the views of other professionals involved in the care provision of the people living in the home is sought as part of monitoring that the service is meeting it’s aims and objectives. 2. 3. 4. YA20 YA34 YA39 Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Fch - Nairn Close/Orkney Close DS0000004360.V300344.R01.S.doc Version 5.2 Page 27 - 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. 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