Inspection on 14/12/05 for New House

This inspection was carried out on 14th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

New House 23/06/06

New House 08/03/06

New House 13/01/05

New House 17/08/04

New House 28/01/04

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 New House Behoes Lane Woodcote Reading RG8 0PP Lead Inspector Nancy Gates Announced Inspection 14th December 2005 09:30 New House DS0000013117.V252831.R01.S.doc Version 5.0 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 New House DS0000013117.V252831.R01.S.doc Version 5.0 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. New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service New House Address Behoes Lane Woodcote Reading RG8 0PP 01491 681874 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) londonroad@tiscali.co.uk Milbury Care Services Limited Care Home 8 Category(ies) of Learning disability (8) registration, with number of places New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2005 Brief Description of the Service: New House is a detached home in the small Oxfordshire village of Woodcote near Reading. The home provides support to six people who have a learning disability. Each person has a variety of needs; some individuals needing support for mobility issues. Residents are supported on a 24-hour basis by a staff team who are employed by Milbury Care Services who are part of the Paragon Group. New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector was in the home from 10.30am until 7.00pm on a weekday. Residents were in the home at various times within the inspection visit. There were seven staff members on duty including the manager and the deputy manager. Staff members were generally welcoming, although residents were not at home for the majority of the inspection. The inspector looked around all of the building, including residents’ bedrooms, but this could not be undertaken with their permission due to individuals not being available. A number of records were inspected including the personal records of service users, and the personnel records of staff members. Two staff members were spoken with. No visitors were available to speak with, although feedback was received from residents’ doctors and health care professionals. What the service does well: What has improved since the last inspection? No requirements or recommendations were made at the previous inspection. New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 6 What they could do better: The care and support records held for residents contain a large amount of information that does not necessarily relate to current needs. Information gathered on a daily basis is related to tasks, is not clearly cross-referenced to risk assessments or does not contribute to guidance as to how a person likes to be supported. The lack of structure and appropriateness of information places service users at risk and must be addressed. Custom and practice features in the method of support used by a number of staff. Emphasis is placed upon the use of tick charts relating to physical health needs. This does not guide the reader of support plans to understanding individual’s wishes in how they like to be supported. This suggests an institutionalised approach to supporting people. Many staff took a guarded approach during the inspection. Staff opted to be out of the home as much as possible, due to custom and practice encouraged by the previous manager, but this did offer opportunity for residents to go out that did not relate to the structured activity plan posted within the home. The approach to mealtimes again highlighted custom and practice. Mealtimes are based upon sittings relating to the behavioural support needs of individuals. The sittings cannot ensure that each person is served with the same quality/consistency of food. Food is either “kept warm by leaving it in the oven” or “re-warmed in the microwave”. Food temperatures are not being recorded. Task orientation does not allow for mealtimes to be a social activity as well as a necessity. Relationships with residents’ doctors are good. Relationships with health care professionals from the Community Team for People with Learning Disabilities need to be improved to ensure that residents are receiving appropriate health care support when required. The cutting of residents’ hair does not give individuals the opportunity to have their hair cut professionally and does not recognise them as individuals. Administration of medication does not currently follow instruction and does not ensure the protection of residents. A number of environmental issues present serious risk to the health and safety of residents and staff. • • • • • One person has bars at their bedroom window; no risk assessments or guidance were available. The kitchen is outdated and very dirty in all areas. A fire exit was restricted. Infection control issues within a bathroom. No radiator covers (no risk assessments apparent). DS0000013117.V252831.R01.S.doc Version 5.0 Page 7 New House Further environmental issues were raised that impact on the comfort, health and welfare of all household members. A lack of cleanliness in many areas demonstrates a lack of respect in relation to the house being the residents’ home. Moving and handling techniques demonstrated by a staff member do not ensure the safety of residents. A review of practice and knowledge in relation to moving and handling techniques should be undertaken to ensure the health, safety and welfare of residents and staff. The lack of a registered manager has placed residents at risk due to responsibility for all aspects of care, including health and safety falling to the registered provider who has not been in day-to-day contact with the home. The registered provider has neglected to ensure that the registration of a manager with the Commission is undertaken. A new manager has been appointed and the CSCI have received an application for registration. The inspector welcomes and acknowledges the immediate response of the provider to address a number of issues highlighted within the inspection. An action plan has been provided to the CSCI. 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. New House DS0000013117.V252831.R01.S.doc Version 5.0 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 New House DS0000013117.V252831.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No new admissions have been made to the home. The standards in this section were not assessed on this occasion. EVIDENCE: New House DS0000013117.V252831.R01.S.doc Version 5.0 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&9 Support plans contain numerous documents that do not relate to the current support needs of individuals. Information gathered on a daily basis is not cross-referenced to risk assessments or does not contribute to guidance as to how a person likes to be supported. The lack of structure and appropriateness of information gathered places service users at risk and must be addressed. EVIDENCE: The care plans of four residents were viewed. The documents do not provide clear information as to how each person likes to be supported and it was clear that the individuals had not contributed throughout the whole process of writing the plans. The plans related to a person’s communication support needs in areas, but do not clearly identify and guide staff in the interpretation of sound and gesture for some individuals. The inspector acknowledges that working relationships have been established with staff over a number of years but plans need to provide clear information for the protection of both residents and staff. The plans were not consistent in relation to clear description and recognition of who people are as individuals and cannot contribute to establishing trusting and supportive relationships with new members of staff. New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 11 Files contained a considerable amount of tick charts. One chart, which was the first document in a number of files, requested the following information to be completed for each day. “Bath, Bowel Movement, Menstruation, Outburst, Incontinence, Clean teeth, Fingers, Toe Nails.” The plan indicated that staff are cutting residents’ fingers and toenails. This must be addressed as this can place individuals who may have specific health needs at considerable risk and must also relate to guidance within the local Shared Care Protocol. The tick charts were not cross-referenced to other documents and therefore did not validate the reason for collecting the information. This presents an institutionalised/custom and practice approach again demonstrating the residents are not necessarily regarded as individuals with differing needs. The plans did not fully give opportunity for personal likes and wishes to be prioritised in order of individual personal preference. Reactions to “outbursts” and approaches to behavioural support needs did not indicate that consistency and current best practice is considered, for example, “Guidelines to prevent or reduce X’s outbursts and how to handle them”. The daily notes for the individual highlighted a lack of understanding, “Return from day centre, ate well, had a little outburst, took herself upstairs but soon came back downstairs. When we did not follow her she settled down.” Risk assessments have been undertaken but have not been reviewed regularly. New House DS0000013117.V252831.R01.S.doc Version 5.0 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): 17 The staff team does not assure the quality and consistency of food provided. Custom and practice determines how meal times are managed and does not allow for mealtimes to be a social activity as well as a necessity. This suggests an institutionalised approach to supporting people. EVIDENCE: The inspector was able to observe staff support residents to eat lunch and their evening meal. The menu plan for the day detailed that beef or ham and salad sandwiches would be served for lunch. One resident was served with a cheese sandwich on white bread; another served with a pasta dish. Residents were supported in a 1st, 2nd & 3rd sitting, staff stating that this was due to differing behavioural support needs. For example one person was stated to not like sitting with other house members and so sits at the table with one staff member supporting. Staff ate beef or ham and salad sandwiches on wholemeal or white bread. New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 13 Staff stated that the first sitting is for three residents who have differing but high levels of support required, the second sitting is for one individual, and the third is for two residents who require minimum support and it is at this time that staff will also eat. A staff member described that “it is easier to help people and you don’t get so messy, because food can go everywhere. The new manager wanted everyone to eat together but we don’t think this works, the sittings are easier.” This demonstrates that staff are managing the support of individuals in a task-orientated manner; mealtimes do not appear to be a social activity. Exploring how staff ensure that each person is served with the same quality/consistency of food raised a number of concerns. Staff stated that when hot food is prepared and served residents at the first sitting are provided with the freshly cooked meal. To ensure the food remains hot for the further two sittings it is either “kept warm by leaving it in the oven” or “re-warmed in the microwave.” Records indicate that the last occasion that food temperatures were recorded was on the 22.06.05. The quality of the food served cannot be assured. The inspector observed staff supporting people to eat their evening meal. Staff were seen to be wearing blue plastic aprons and blue non-latex gloves, again underpinning an institutional approach to supporting people. Residents’ support requirements have been recorded. The inspector acknowledged that changes have been proposed following the inspection allowing staff to contribute to looking at mealtimes being a social opportunity whilst recognising the behavioural support needs of individuals. New House DS0000013117.V252831.R01.S.doc Version 5.0 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): 19 & 20 Relationships with residents’ doctors are good. Relationships with health care professionals from the Community Team for People with Learning Disabilities need to be improved to ensure that residents are receiving appropriate health care support when required. Cutting residents’ hair does not give individuals the opportunity to have their hair cur professionally and does not recognise them as individuals. The administration of medication does not currently follow instruction and does not ensure the protection of residents. EVIDENCE: Residents are supported to access health services and are registered with a local doctor. Positive comments have been received from local doctors. Staff are appropriately referring residents for treatment. Medication reviews are conducted with the doctors on a regular basis. An incident involving one service user has been supported through the adult protection procedure but recommendations by health care professionals; the individual’s doctor and placing/quality monitoring officer have not been New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 15 followed through to ensure the individual’s physical and emotional health needs continue to be met. A cutting guard/attachment comb for hair clippers was found in a service user’s room. It was stated that staff would cut residents’ hair due to a behavioural incident that appended in a hairdresser preventing some individuals from going to get their hair cut professionally. Guidelines were not apparent. This raises questions as to whether people are being regarded as individuals and whether alternative hairdressers can be sought. The medication administration records (MARs) were viewed. Records indicated that two members of staff were not giving medication at the time indicated upon the MARs. There was no record of a change in time of administration directed by the individual’s doctor. A signature list of staff that have been assessed as being competent to administer medication was not available. The inspector was unable to establish whether the correct staff are administering medication. The inspector acknowledges the immediate action taken by the manager to reassess the competency of the members of staff to ensure the safety of residents. New House DS0000013117.V252831.R01.S.doc Version 5.0 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): The standards in this section were not inspected on this occasion. EVIDENCE: New House DS0000013117.V252831.R01.S.doc Version 5.0 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, 26, 27, 28, 29 & 30 A number of environmental issues present serious risk to the health and safety of residents and staff. The lack of cleanliness demonstrates a lack of respect in relation to the house being the residents’ home. This also impacts on the health and safety of residents. Improvement to a significant number of rooms within the house is needed. EVIDENCE: A significant amount of time was taken to assess the standard of accommodation provided to residents. The inspection of the premises raised major concerns in relation to both inside and outside the home. The internal appearance of the home was of a reasonable standard although some areas appeared scruffy. Service users’ bedrooms reflect individual tastes, containing personal effects that suggest that individuality is recognised. New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 18 A number of issues were identified within the tour of the home and are described room by room. • Lounge: Reasonable standard of fixtures and fittings. A member of staff has donated a suite of leather furniture and whilst generous, raises questions why the service provider is not providing adequate furniture for residents’ use. Dining area: A large table with a number of chairs are available. The table was covered with a vinyl tablecloth but this was sticky to the touch. Sensory area: A designated sensory area is next to the dining area. The room contains a mattress and sensory equipment but is also a thoroughfare from the kitchen to the dining area. Ground floor bathroom: The bathroom contains a specialist bath. Staff stated that the bath was donated a number of years ago. The internal bath surface is cracked and could present issues of infection control. The bath plug chain is rusty in areas. The plug was attached to the chain by a small piece of fabric that was stained and was wet to the touch. The bath had not been used for a number of days due to the overhead ceiling-tracking hoist not working; therefore the fabric clearly remains wet and again presents infection control issues. A plastic showerhead is attached to the bath: the pipe and showerhead were discoloured and a number of the showerhead holes were blocked. Tiles and grouting behind the bath were dirty. The ceramic handle of the toilet was cracked. The sink had no plug. Ground floor bedrooms: An individual’s bedroom held a strong odour of urine. Staff stated that the individual has continence support needs but there was no evidence of a continence assessment or a clear plan of how the resident’s needs were being met. New flooring has been fitted to an individual’s bedroom but is clinical in appearance and does not reflect a comfortable/homely space. Kitchen: The kitchen was very dirty in all areas. Saucepans, baking trays, cookware and chopping boards were well used and are in need of replacement. Fridge and freezer temperatures had only been recorded on the 12th, 13th and 14th December 2005, no other records were apparent. Food temperature records were last recorded on the 22nd June 2005. Please refer to the evidence relating to food temperatures in Standard 17. Guidelines regarding the needs of residents were posted on kitchen walls and whilst important to know not respectful of the house being the residents’ home. An inspection by an Environmental Health Officer is required throughout the house. Stair well: Two large sheets of hardboard have been attached to the first floor and top stairwell handrail. Staff stated that the boards had been needed due to a resident sliding down the handrail, that the boards were to reduce the risk of the individual falling. No risk assessment or guidelines were available. • • • • • • New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 19 • Upstairs bedrooms: One resident has locked concertina bars at their bedroom window that can be seen from the road at the front of the house. No keys were available to unlock the bars. Written information to support the use of the bars i.e. risk assessments or guidance was not available. This presents serious risk to the health, safety and welfare of the individual as well as potentially presenting a negative view of the person to the wider community. Bedsides are used on two residents’ beds. No risk assessments or guidance were available. One of the beds was pushed up against a radiator, which at the time of inspection was very hot to the touch and did not have a radiator cover. A clear risk to the individual. The inspector noted that there are no radiator covers throughout the home. A shared bedroom has an en-suite bathroom. Two people who have very different physical support needs share the room. A ceiling track hoist is available for one individual who has mobility support needs. The en-suite bathroom has a standard bath, which meets the needs of one resident but presents issues for the other. A slip bath insert has to be used to support the other individual. A bath insert does not allow for a person to be fully immersed in water potentially leaving areas of skin exposed and when wet leading the person to become cold. A bath insert may also present issues in relation to back injury to staff. The low level of the bath requires a staff member to bend down to assist or to kneel beside the bath. A screen is used in the middle of the room and curtains are used at the entrance to the en-suite bathroom in an attempt to provide privacy. The curtains do not close properly. They are hung by the use of a curtain wire that has become unstrung and does not allow for the curtains to close completely. The use of the screen whilst blocking the view cannot provide complete privacy when personal care and support are being provided. Staff have stated that the residents have shared a room for a number of years and that it would have a negative effect to provide a single room for each person. The inspector urges the service provider to consider whether, in line with the national minimum standards, residents continue to make a positive choice to share and whether the room provides at least 16 square metres usable floor space, excluding the en-suite. There was no evidence available to establish whether privacy and dignity are supported and maintained and whether the room and en-suite meet the needs of both individuals. New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 20 A tour of the back garden raised the following issues: • Fire exit: Upon opening the fire exit closest to the kitchen a large collection of fallen leaves filled the ramp exiting to the garden. A latex glove was also present amongst the leaves as well as on the roof of the single storey extension next to the exit. The branches of a large tree, from a neighbour’s property obstructed the exit down the ramp. Patio slabs at the bottom of the ramp were loose and unstable. Window frames: The stain/varnish on wooden window frames was peeling and discoloured. Garden & garden furniture: A number of plastic chairs were strewn across the garden. A large trampoline is available but there was no documentation available to determine that appropriate instruction and certificated teaching had been undertaken to ensure the safety of individuals. • • New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 Staff records indicate that the recruitment process is adhered to and that residents are protected. Training opportunities provide staff with the knowledge required to support residents’ needs. Moving and handling techniques demonstrated by a staff member do not ensure the safety of residents. EVIDENCE: The recruitment records are held at the home and contain the relevant information for the protection of all house members. The manager confirmed that Criminal Records Bureau (CRB) checks are undertaken and disclosure numbers are recorded within, as unable to see the CRB checks and reminded the manager that documents must be held in staff files until inspected. CRB checks are held at Millbury Head Office in Henley. The training programme offered by Milbury underpins the knowledge required to support residents (including required subjects), although one staff member was seen to be assisting a resident who uses a wheelchair in an unsafe manner. New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 22 A review of practice and knowledge in relation to moving and handling techniques should be undertaken to ensure the health, safety and welfare of residents and staff. New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 The lack of a registered manager has placed residents at risk due to responsibility for all aspects of care, including health and safety falling to the registered provider who has not been in day-to-day contact with the home. Environmental issues present serious risk to residents and staff. EVIDENCE: A new manager has been appointed at the home following a 10-month period of inconsistency. The registered provider has neglected to ensure that the registration of a manager with the Commission is undertaken. A new manager has been appointed and the CSCI are awaiting an application for registration. Evidence regarding health and safety issues is indicated within the environment section of the report. New House DS0000013117.V252831.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 X X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 2 1 2 2 1 LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 New House Score 2 2 2 X Standard No 37 38 39 40 41 42 43 Score 1 X X X X 1 X DS0000013117.V252831.R01.S.doc Version 5.0 Page 25 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 YA6 Regulation 15 Requirement The registered person must ensure that residents have clear, up to date assessments and support plans. The registered person must ensure that risk assessments are completed and reviewed. The registered person must ensure that adequate kitchen equipment and kitchen facilities are of a good standard for the use of residents and staff. The registered person must ensure that a nutritionally balanced diet is available to all residents and is served at the correct temperature. The registered person must ensure that medication is administered at the time stated upon medication administration records. The registered person must ensure that the home is kept in a good state of repair externally and internally and that a maintenance schedule is produced on an annual basis. The registered person must ensure that the garden space DS0000013117.V252831.R01.S.doc Timescale for action 31/05/06 2 3 YA9 YA17 13:4 (a), (b) & (c) 16 (g) & (h) 28/02/06 16/02/06 4 YA17 16 (i) 08/02/06 5 YA20 13 (2) 08/02/06 6 YA24 23(2) (b) 08/02/06 7 YA24 23 (2) (o) 31/03/06 New House Version 5.0 Page 26 8 9 YA24 YA24 23 (4) (a) 13 (4) (a) 10 YA25 23 (2) (f) 11 YA27 23 (2) (j) 12 YA30 23 (5) provided is appropriately maintained and that patio areas are safe for use. The registered person must consult the Fire Authority/Officer to ensure that the home is safe. The registered manager must ensure that the use of bars at bedroom windows and the use of bedsides are adequately risk assessed to ensure the safety of household members. This must be related to the visit to be conducted by the Fire Authority. The registered person must review the use of a shared room and whether it meets the needs of both individuals. The review must consider individual’s privacy and dignity needs. The registered person must ensure that the shared en-suite bathroom adjoining the shared bedroom meets the needs of both residents. The registered person must contact the environmental health officer to review the premises and practices within the home. The registered person must ensure that an application for a Registered Manager is submitted to the CSCI. 08/02/06 28/02/06 28/02/06 01/03/06 08/02/06 13 YA37 8 20/02/06 New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA19 YA20 YA35 Good Practice Recommendations Relationships with health care professionals need to be established and maintained to ensure that residents receive support for health care needs as required. A signature list of staff that have been assessed as competent to administer medication should be held within medication administration records. A review of practice and knowledge in relation to moving and handling techniques should be undertaken. New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 New House DS0000013117.V252831.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!