Inspection on 29/08/06 for One-Six-One

This inspection was carried out on 29th August 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 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

One-Six-One 24/09/07

One-Six-One 26/02/07

One-Six-One 11/10/05

One-Six-One 19/04/05

One-Six-One 01/10/04

One-Six-One 16/04/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 One-Six-One The House 161 Wootton Road King`s Lynn Norfolk PE30 4DW Lead Inspector Mrs Lella Andrews Unannounced Inspection 29th August 2006 12:00 One-Six-One DS0000027509.V310299.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 One-Six-One DS0000027509.V310299.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. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service One-Six-One Address The House 161 Wootton Road King`s Lynn Norfolk PE30 4DW 01553 673194 01553 674395 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) One-Six-One Limited Mr Andrew Orford Care Home 8 Category(ies) of Learning disability (8) registration, with number of places One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th October 2005 Brief Description of the Service: One-Six-One is a care home providing care to eight people with learning disabilities. It is situated in a residential area of Kings Lynn, approximately a mile from the town centre. There are local shops, a library and other amenities within the immediate vicinity of the home. The premises consist of accommodation on three floors accessed by stairs. There are two reception rooms, kitchen, dining area and laundry on the ground floor. Bedrooms are located on ground, first and second floors. The home was extended in the spring of 2002 to provide two further bedrooms and to improve the standard of accommodation to others. The home has patio, decking and garden areas to the rear. The home provides care for ambulant people who may require consistent support for their behavioural needs. Service users access a variety of day activities and services available locally. The home has its own transport. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report includes information gathered during an unannounced visit to the Home which was carried out between 12 and 6.30pm on Tuesday 29th August. This included a tour of the building, discussion with the Manager and three members of staff as well as discussion with one of the clients and observation of staff and clients together. Records and the medication system were inspected. The report includes information from five completed comment cards received from clients, two from relatives and two from health/social care professionals. Any regulatory action and events notified to the Commission were also considered as part of this inspection. There are currently only five clients living at the Home. The fees range from £1,000 to £4,000 per week and are negotiated on an individual basis prior to the client moving into the Home. What the service does well: The Home provides a good standard of accommodation for the clients and has an ongoing maintenance and improvement plan. The clients are supported to take part in a range of activities and to access the local facilities. Clients comments include: “ I can always go for a drive when I want to” “Theres lots of things to do…” The care plans, in general, contain good information about how to meet the needs of the clients. The clients said that they like the staff and that the staff listen to them. Clients comments include: “…I get on with the staff” “…Staff easy to talk to” One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 6 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. One-Six-One DS0000027509.V310299.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 One-Six-One DS0000027509.V310299.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): The key standard was not inspected, as there have not been any admissions to the Home since the previous inspection. EVIDENCE: One-Six-One DS0000027509.V310299.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 group is adequate. This judgement has been made using available evidence including a visit to the service. The care plans are used by staff to inform the support that they provide but there is a need for some areas to be more detailed. Risks are considered and briefly recorded but there is a need for these to more detailed in some instances. Improvements need to be made to the system for looking after clients money to ensure that the system is more easy to audit and to ensure that all involved are clear about their responsibilities. EVIDENCE: Two of the care plans were seen. These contain lots of clear information about the individual needs of clients and how to meet these needs. There is a lot of information about how to support clients when their behaviour is “challenging” with the emphasis on avoiding known triggers and diverting situations rather than a reliance on physical intervention. However, on occasion physical One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 10 interventions have been used and a requirement is made for these circumstances and procedures to be clearly documented within the care plans. This is a repeat requirement from the previous report. However, improvements have been made as a clear record is being kept following incidents of physical intervention and four staff, including the manager, have attended relevant training. The manager is in the process of finding out which method of training will be most appropriate for the staff team to ensure that it is appropriate for the needs of the clients and that all staff receive consistent training. A requirement is made with regard to this. All four of the clients who completed comment cards state that they are aware that they have a care plan. The staff are aware of the content of the care plans and said that they have access to them. Staff complete brief daily notes and in addition to this complete detailed incident forms where appropriate. The care plans contain risk assessments which are fairly brief but seem to be adequate. However, a requirement is made for a risk assessment to be carried out with regard to the use of physical interventions. The Commission had received a complaint about the arrangements in place for looking after clients money. The outcome of this investigation is covered in a separate report. However, the requirements from the investigation are repeated in this report. The arrangements relating to the financial affairs of another client were looked at during the visit and the same shortfalls in the system were found as for those relating to the client whose financial affairs were the subject of the complaint. In general, the Manager and deputy were able to explain the system in place but there is a need to ensure that the records and procedures clearer so that the system is easier to audit and so that everyone is aware of their responsibilities. A requirement is made for each client to have a financial care plan which clearly states the agreements in place for looking after clients money. A requirement is made for clients to pay any charges, such as mileage, on at least a monthly basis. A requirement is made for the statement of terms and conditions to include the fees payable for each client and to clearly state the rates payable for any other charges, such as mileage. A requirement is made for the holiday procedure to more clearly explain the rates of charges for holidays. The client who spoke to the Inspector gave several examples of how they are supported to make their own decisions about a range of issues. The care plans contain references to the individual clients choices and preferences. Discussions with staff show that they are committed to supporting the clients to be as independent as possible and to make informed choices in as many situations as possible. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 11 The Home does not have “house meetings” as the Manager does not feel that these are beneficial for the group of clients living at the Home. The Manager is considering ways of recording how the views of the clients are sought. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 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): 12, 13, 15, 16 and 17 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. Clients are supported to access a range of leisure activities. Contact with relatives is encouraged and relatives are made to feel welcome. The privacy of the clients is respected. EVIDENCE: Two of the five clients attend formal day services away from the Home whilst another receives support away from the Home from two members of staff for seven days per week. A car is available to this client and the supporting staff. The other two clients receive support from staff to access a variety of activities. Staff said that the staffing levels are adequate to ensure that clients can be supported to go out during the evenings and at weekends. One of the clients comment cards states that they would like more things to do but the inspector was unable to clarify this with them and evidence shows that they One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 13 have a very varied and full programme of activities. The other comment cards state that the clients have lots of things to do. The two clients who attend day centres have had a fortnight of additional activities arranged with them for the two weeks that the day centres have been closed. The care plans contain information about individual likes and dislikes with regard to social activities. Risk assessments are available relating to supporting clients away from the Home. The Home has access to three cars, all of which are shared between this Home and the other, smaller, Home owned by the same organisation which is situated next door. A comment was made in a clients comment card about one of the good things about living at the Home is “I can always go for a drive when I want to”. All of the completed comment cards from relatives and clients state that clients are able to have visitors and that they are made to feel welcome. The care plans contain information about the arrangements in place to enable clients to maintain contact with relatives and friends. The Home is situated close to the town of Kings Lynn and the clients regularly use the facilities there, such as pubs, bowling alley, cinema, shopping centre and restaurants. One of the clients regularly walks to the local shop to buy magazines and other items. Staff respect the privacy of the clients. Two clients told the Inspector that they have their own keys to their rooms and staff always knock and wait prior to entering. They said that they are able to spend as much time in their rooms as they like and have access to all parts of the Home with the exception of other clients bedrooms. One of the comments in the clients comment card states that one of the good things about living at the Home is “being able to get up when I want”. A concern was raised by a relative about the lack of choice of meals and one of the clients comment cards state that they do not have choice about what they have for dinner. However, during the visit two clients told the inspector that they are offered a choice at every meal and this was confirmed by the staff. The cook was on leave on the day of the inspection and so staff were responsible for preparing and cooking meals. The cook writes a menu and then clients are asked if they would like to have what is on the menu or if they would prefer something else. A record of what each client has for meals is recorded and this shows that, very often, a variety of meals is provided at each mealtime. The kitchen has recently been refitted which provides more useable space for whoever is cooking. There are still some minor jobs to be completed before it is completely finished. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 14 The comment cards state that the clients are not involved in the shopping and this was found to be the case but mainly because the Home has food delivered rather than go to the supermarket. Fresh fruit, vegetables and meat is delivered on a weekly basis and the supermarket also delivers. Clients are involved in shopping for additional items, such as milk and bread as well as any items that they may wish to buy themselves. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. There are mixed views from the health/social care professionals about whether the needs of the clients are met at the Home. Medication is well managed with staff receiving training so as to ensure the protection of the clients. EVIDENCE: The care plans now contain more detailed information about the health needs of the clients which is an improvement since the last inspection. Staff have all received training so as to be able to assist a client with the administration of insulin. Staff also receive training with regard to the administration of medication and about aspects of mental health. Staff were heard making arrangements for dental treatment which took in account the particular needs of the client. None of the clients currently need assistance with personal care or mobility. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 16 Two completed comment cards were returned by health/social care professionals. These contain conflicting information with one stating that the home communicates clearly with them and works in partnership and the other stating that this only happens sometimes. One states that the staff demonstrate a clear understanding of the care needs of the clients and one states that this does not happen. Both comment cards state that medication is appropriately managed. One of the comment cards states that the management do not take appropriate action when they can no longer manage the care needs of the clients. The recommendations made during the previous inspection about medication have been met. The system in use was seen and this is satisfactory with appropriate records being kept. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome group is poor. This judgement has been made using available evidence including a visit to the service. The overall judgement is poor due to the ongoing investigation into the allegation of abuse. The Home has a complaints procedure and the clients are aware of who to complain to. Staff need to receive training with regard to the protection of vulnerable adults and the whistle blowing policy to further protect the clients. The Protection of Vulnerable Adults procedure is not accurate and so does not provide adequate guidance for staff following an allegation. EVIDENCE: The Home has a complaints procedure and the clients comment cards all state that they are aware of who to speak to if they are unhappy. This was confirmed by one of the clients who spoke to the Inspector. The relatives comment cards state that they are aware of who to make a complaint to but that they have not had to complain. Again the views of the health/social care professionals are mixed with one stating that no complaints have been made to them about the service while the other states that complaints have been made to them. The Commission received a complaint regarding the financial arrangements for looking after clients money. This has been investigated and no evidence of financial abuse found. However, the requirements made as a result of the complaint investigation are repeated in this report. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 18 The Home has a protection of vulnerable adults procedure, which is out of date and inaccurate. Some staff have received training with regard to this subject. It is required that all staff receive training. It is required that the POVA procedure is updated and is accurate. The staff who spoke to the Inspector said that they are aware of their responsibility to report any concerns about abuse and they are confident that these would be dealt with appropriately. However, information provided to the Inspector causes some concern about whether the whistle blowing policy is really understood and supported by the staff and manager. It is recommended that training is provided to the staff team so that there is a real understanding of the purpose and process of the whistleblowing policy. There is currently an outstanding adult protection situation at the Home which is not yet resolved. The management of the Home are working appropriately with all others involved in the investigation into this situation. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The Home provides a good standard of accommodation for the clients. The organisation has plans in place for the continuous improvement of the environment. EVIDENCE: A tour of the communal areas of the Home and of the empty bedrooms was undertaken. Two of the clients showed me their bedrooms. The clients bedrooms are personalised and the clients are clearly encouraged to decorate and furnish them in a manner of their choosing. It is recommended that the carpet in one of the bedrooms seen during the visit is cleaned effectively or replaced as it is quite marked. The Home is attractively decorated and furnished throughout in a homely manner. The clients clearly feel able to use any of the communal areas that they wish to. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 20 The Home has a programme of ongoing maintenance and improvement. Since the last Inspection the hallway has been redecorated and a new front door fitted. A shower has been put into one of the bedrooms. A new kitchen has been fitted and is almost complete. There is a small area in the lounge which requires attention to the plaster/paintwork and the Manager said that this is being addressed. The Home has a separate laundry room which the clients are encouraged to use for their own personal laundry. The majority of the Home was clean with no unpleasant smells except for one of the bathrooms on the first floor and it is required that the unpleasant smell in this room is removed. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. Clients feel that they are well cared for and that the staff listen to them. Staff receive induction and training although there are additional areas of training which would ensure that they are able to provide good care in a consistent way. Appropriate recruitment procedures are followed. Staff would benefit from receiving supervision on a more frequent basis. EVIDENCE: The Home does not currently meet the standard of 50 of staff having achieved NVQ level 2 but there are plans in place for this to be met. The staff who spoke to the Inspector have a good knowledge of the needs of the clients and of the plans in place to meet these needs. They are enthusiastic about their role and genuinely appear to enjoy working with the clients. The staffing levels are satisfactory. There are less staff on duty than in previous inspections as there are only five clients currently living at the Home. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 22 One of the clients receives 2:1 support during the day for seven days per week. The recent appointment of senior members of care staff seems to be working well with staff clear about the roles of individual members of the team. The deputy manager has received appropriate training and is taking on more of the management tasks. All of the clients comment cards state that they feel well cared for and that the staff treat them well and listen to them. Two of the cards additionally stated that one of the good things about the Home is the staff. The staff said that the team works well together. It is recommended that team meetings take place on a regular basis. The two comment cards received from health/social care professionals again differ in their views about whether the staff demonstrate a clear understanding of the needs of the clients with one stating “yes” and one stating “no” The Service Manager has recently left the Home and her tasks, including induction, are being divided between the Manager and the deputy manager. Records of induction for new members of staff were not seen as the Inspector was told that these were at the other office where induction takes place. However, the Manager said that the induction has been taking place in the same way as it used to before the Service Manager left. Staff receive training about a range of issues. Requirements about training have been made elsewhere in this report. It is important that the Manager ensures that staff receive formal training as well as that provided by the use of videos and questionnaires. Supervision has not taken place quite so regularly since the Service Manager left but the deputy and the Manager have taken this on between them and have provided supervision to staff. Records were seen to evidence this and the staff confirmed that they have received some formal supervision over the last few months. It is recommended that supervision is provided on at least a two monthly basis. Appropriate recruitment procedures take place when appointing new members of staff. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42 Quality in this outcome group is poor. This judgement has been made using available evidence including a visit to the service. In general, the management and staff take health and safety matters seriously. However, the issues relating to restraint, the allegation of abuse and the dog mean that the protection afforded to the clients is currently not as robust as it should be. The management and staff do obtain the views of the clients in a range of issues but there is a need to formalise all of the quality assurance processes. EVIDENCE: The Inspector was given a lot of examples throughout the visit of how the views of the clients are sought on a daily basis about a range of issues. The Manager is aware of the need to formalise these views, possibly through the use of a questionnaire or a record of clients input at care plan reviews, as part of the overall quality assurance process. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 24 The Manager also said that he intends to implement a more formal process of communicating with relatives such as regular meetings throughout the year so that issues can be dealt with in a prompt manner and so that relatives feel confident that their views are taken into account with regard to their relatives care. The development plan has not been completed for the year 2006/07 but the Manager has plans to complete this which will include updates on work planned in the plan for 2005/06. The manager said that questionnaires were sent to relatives and professionals in February 2006, with six returned. The analysis of this data will be used as part of the planning for the forthcoming development plan. The analysis provided by the manager shows that overall relatives and professionals were mixed in their views about the overall quality of the service with all rating as either adequate and moving towards good, good or excellent. It is required that an annual quality assurance report is produced and that a copy is sent to the Commission. It is also required that monthly visits are carried out as per Regulation 26 and a report sent to the Commission. The Service Manager used to carry these visits out but is no longer working at the Home. The Inspector saw a range of records relating to health and safety, including equipment maintenance, accident, restraint and incident records. The Manager has been let down by the usual engineer and so the maintenance of the fire safety equipment has not been carried out as regularly as it should and a requirement is made with regard to this. However, the Manager was addressing this situation on the day of the visit. The Manager also said that the boiler and gas safety check are due to be carried out in September. A member of staff has been appointed to take on the responsibility for fire safety and is due to attend relevant training later next month. He has started to maintain the records relating to staff training and organise fire drills. He will also complete the necessary fire risk assessment once he has attended the training. The Home has a dog which belongs to the clients. The accident book shows that the dog has bitten two staff recently. The Manager said that he has discussed the dog with the clients and that they are all keen to keep her. It is required that a risk assessment is carried out with regard to the safety of keeping the dog. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 25 There are issues relating to the health and safety of clients and staff which have been highlighted elsewhere in this report. That is the issue of physical interventions (restraint) and the allegation of abuse. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 26 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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 2 X X 1 X One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 27 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, 13(8) Requirement It is required that a detailed care plan is kept relating to the use of physical restraint and any other physical interventions. The previous date of 30/11/05 was not met. It is required that a risk assessment is carried out for the use of physical restraint and any other physical interventions. The previous date of 30/11/05 was not met. It is required that all staff receives effective training with regard to the use of restraint and other physical interventions. It is required that each client has a financial care plan. It is required that the statement of terms and conditions is updated and contains individual information about the fees and any other charges payable by the client. It is required that the holiday policy contains clear information about the charges payable by the client. It is required that the protection of vulnerable adults procedure is DS0000027509.V310299.R01.S.doc Timescale for action 31/10/06 2. YA6 13(4) 31/10/06 3. YA6 YA35 18 (c) 31/12/06 4. 5. YA7 YA7 15 5 30/09/06 31/10/06 6. YA7 5 31/10/06 7. YA23 13 (6) 30/09/06 One-Six-One Version 5.2 Page 28 updated so that it is accurate. 8. YA23 13 (6) It is required that all staff receives formal training about the protection of vulnerable adults. It is required that the odour in the bathroom on the first floor is removed. It is required that an annual quality assurance report is produced and a copy sent to the Commission. It is required that monthly visits take place and that the report is sent to the Commission. It is required that a risk assessment is carried out with regard to the dog. It is required that the fire safety equipment is serviced at appropriate intervals. 31/12/06 9. 10. YA30 YA39 23 (2) 24 30/09/06 31/03/07 11. 12. 13. YA39 YA42 YA42 26 13 (4c) 23 (4) 30/09/06 30/09/06 30/09/06 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. 4. 5. Refer to Standard YA7 YA23 YA24 YA33 YA36 Good Practice Recommendations It is recommended that the clients are charged on at least a monthly basis for those things that they pay for. It is recommended that the whistle blowing policy is discussed with the staff team to ensure all have clear understanding. It is recommended that the carpet seen by the Inspector in the first floor bedroom is cleaned effectively or replaced. It is recommended that regular staff meetings take place. It is recommended that supervision takes place on a more regular basis. One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 One-Six-One DS0000027509.V310299.R01.S.doc Version 5.2 Page 30 - 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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