Inspection on 22/01/07 for Overbrook

This inspection was carried out on 22nd January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Overbrook 10/10/05

Overbrook 06/06/05

Overbrook 08/03/05

Overbrook 21/10/04

Overbrook 19/03/04

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 Overbrook 92 High Street Wootton Isle Of Wight PO33 4PR Lead Inspector Annie Kentfield Unannounced Inspection 22nd January 2007 14:00 Overbrook DS0000012520.V320030.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 Overbrook DS0000012520.V320030.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. Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Overbrook Address 92 High Street Wootton Isle Of Wight PO33 4PR 01983 883390 01983 883390 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) Islecare `97 Limited Dianne Yvonne Mills Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 2005 Brief Description of the Service: Overbrook is a small group home providing care for four adults with learning disabilities. The home is a domestic residence situated in Wootton High Street and is close to local shops and amenities. The property is a two-storey building with a staircase to the first floor. There is no lift. There is level access to the front and rear of the property and a handrail around the garden to assist residents who have a visual impairment. There is off road parking to the front. The home is managed by Dianne Mills. The current scale of charges is from £285.81 to £394.17 per week and there are additional charges for transport, chiropody, hairdressing, alternative therapies, outings and day trips. Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of an evaluation of the quality of the service provided by Overbrook and brings together accumulated evidence of activity in the home since the last key inspection on 10th October 2005. Part of the process has been to consult with people who know the service users including the manager and care staff, two social services care managers who visit residents in the home and two relatives of the residents. The residents in the home are not able to participate in the consultation process. Included in the inspection was an unannounced site visit to the home by an inspector on 22nd January 2007 with a short additional visit on 26th January. During the visit the inspector toured the building, looked at a selection of records and spoke with the manager and three of the care staff. The inspector was also able to observe the interaction between care staff and residents and this was seen to be appropriate and caring and the residents were observed to be well cared for. The responses from the consultations were generally positive. One relative wished to compliment the staff in the home on their “dedication and outstanding care”. What the service does well: Although the four residents do not have the cognitive ability to give a view about life at Overbrook all of the residents appear relaxed and happy and well cared for. In spite of recent staff shortages the home has a core group of experienced and committed staff that interact well with all of the residents. The home provides an environment that is domestic in character with a homely, friendly atmosphere. Staff have a good understanding of residents’ needs, including dietary needs, likes and dislikes. The inspector was in the home during the preparation and serving of the evening meal and all of the residents appeared to eat well and enjoy their meal. The introduction of an advocacy service to one resident has been a positive step towards providing additional support and another resident is receiving additional one-to-one support to enable them to develop further leisure and social opportunities. There is common agreement amongst care managers that the home works well with external professionals to ensure the complex needs of the residents continue to be met. Overbrook DS0000012520.V320030.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. The summary of this inspection report can be made available in other formats on request. Overbrook DS0000012520.V320030.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 Overbrook DS0000012520.V320030.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. New service users moving into the home can expect to have their needs fully assessed and met by the home and to be invited to visit the home before deciding to move in. Although the home has updated the general Service User Guide, specific information about the terms and conditions of living in the home has not been provided to service users or their representatives. EVIDENCE: The four residents have lived in the home for some time and no new service users have been admitted in the last two years. However, the manager is clear that any prospective service user would be invited to visit the home and would have their care needs assessed before a decision is made to move into the home. The last inspection required the manager to update the information about the home and this has been done and the printed information is available in the main hallway. Service users already living in the home would not be able to use this information but it is available to visitors, relatives and service user Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 Page 9 representatives to take away. The guide sets out some general information about the home and has a photograph of the house and details about the rooms, staffing and general facilities. However, it would be recommended as good practice for the home to make sure that service user representatives are given the information about the home. The last inspection also required the manager to ensure that each service user or their representative has a contract or copy of the terms and conditions for the service. Copies of contracts or terms and conditions were not found in the service user files and the manager must make this information available to service users or their representatives. The contract or terms and conditions should set out, for example, what residents who live in the home can expect to receive for the fee they pay, any insurance cover or liability, any additional payments for services and details of the overall care to be provided. Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 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. 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. While opportunities for residents to make decisions and choices in their lives are determined by assessment and recorded in individual personal plans, they lack a ‘person centred’ approach and need to reflect best practice in this area. Residents are supported to make decisions about their lives and are encouraged to be as independent as possible and to take sensible risks, which enhance their enjoyment of life. EVIDENCE: Each resident has an individual personal plan. The inspector viewed a sample of two plans. The intention was to look at the outcomes for residents in general by assessing the information and support, which helps them to express their views and lead the lives that they choose. It is evident that residents are consulted with and offered choices about all aspects of daily living from the clothes they choose to wear to what they would like to eat. The overall policy Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 Page 11 of Islecare is to develop a person centred system of care planning, however, this has yet to be introduced. The manager confirmed that training for all staff in person centred care planning will be taking place in early 2007. Information in personal plans and discussions with the manager and staff on duty provided evidence of them respecting residents’ rights to make decisions. There are limitations with residents’ verbal communication and in the main staff learn the various non-verbal signs, which enable them to understand the wishes of the residents who have communication and visual difficulties. Each resident has a key worker in the staff group who provides the additional personal help and support they require. Based on the residents’ preferences care staff will make arrangements for planned visits to day services, take them shopping, arrange hairdressing or take them out for meals or other entertainment. It was understood from discussions with the manager and staff that the arrangements work well when there are sufficient staff to undertake the tasks; an issue dealt with later in the report. One resident has recently been introduced to an advocate and another resident has some additional support for four hours per week to develop social and leisure opportunities. Residents do not have the cognitive ability to manage their own finances and need staff to assist them. During the site visit the inspector looked at the systems in place and found them to be satisfactory. The inspector noted specific risk assessments on the sample of residents’ personal plans. Risks are identified, and to what degree. Guidance is given for staff on what to do to reduce the risk. Overbrook DS0000012520.V320030.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to take part in a range of activities appropriate to their age and individual likes and dislikes. However, recent staff shortages have limited their opportunities for social activities. Residents are supported to maintain regular contact with family and friends. Residents are offered meals they enjoy, which are varied and healthy. EVIDENCE: The manager and staff said the home explores different activities to stimulate and challenge the residents. Their assessed needs are such that seeking jobs or training for them is not appropriate. A weekly programme of activities ensures that the lives of the residents are as varied and interesting as possible, although this only applies to daytime activities. These activities Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 Page 13 include: aromatherapy, shopping trips, visits to a pub or cafe and several day services. The manager said that the lack of qualified drivers in the current staff team has been an additional obstacle to overcome. On the day of the unannounced visit to the home, one of the residents had not attended a planned session at the day centre because there had been no one to drive her and alternative transport had not been arranged. Two of the four residents maintain contact with their families. The staff support one resident to visit family away from the home if required. A relative of one of the residents indicated that staff welcome them in the home at any time. During the second visit to the home one of the residents had a friend to visit who was also invited to stay for lunch. As outlined above the inspector noted limitations with the opportunities for residents to access leisure activities due to staff shortages and lack of drivers. It was evident that limitations extended to residents’ option of a minimum seven-day annual holiday away from the home. It was understood that due to residents’ physical, health and behaviour reasons it was not appropriate for residents to holiday away during 2006, however, residents had not been offered the opportunity to have day trips out as an alternative, due to staffing shortages. Bedrooms were seen to be well personalised and reflect residents’ different interests and preferences. Staff respect their privacy and were seen to knock before entering their rooms or bathrooms and to address the residents by their preferred names. During the site visit the inspector observed the interactions between staff and residents. Staff showed understanding, patience and respect for their privacy. Residents in the home are not able to participate in the household tasks and only one resident is able to move around the home independently, however, the manager and staff said that all of the residents like to use the garden in the summer months and there is suitable outdoor seating and a table. Some of the residents enjoy listening to music and there is a music player in the sitting room and residents’ have their own music systems in their rooms. During the site visit the inspector had an opportunity to observe the evening meal being eaten by residents, and to speak with the support worker who was preparing it. Given the size and domestic character of the home the staff take turns to cook the meals. This seems to work well and certainly residents were observed to eat well and enjoy the meal. All staff spoken with considered the meals were well received by the residents. They said they knew through several years experience what residents liked and needed in their diet. Menus were seen as varied and nutritious, with plenty of fresh food, including vegetables. Packed lunches are made for when residents are at the day centre or there is a choice of snack for lunch if residents are at home. Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 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. 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. The health needs of residents are well met with evidence of good multidisciplinary working taking place on a regular basis. Generally, medication is appropriately administered and recorded but the manager must review some of the systems in place to ensure good practice at all times. EVIDENCE: Records showed that residents’ health care needs are regularly addressed. They receive checks from the GP, dentist, optician and specialist health care professionals. All health care needs of the residents are identified in their personal plans. The manager said that all residents are registered with the local GP surgery close by. Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 Page 15 Both care managers confirmed in discussions that staff had a good understanding of residents’ healthcare needs, and kept them informed of important events affecting their well being. The inspector looked at the home’s arrangements for residents’ medication. Records showed that medication is administered by staff that have been trained and deemed competent by the manager and it was evident that care staff have a good knowledge of each resident and their medication needs. However, the record of competency is not dated and should provide evidence of how staff are assessed as competent and this needs to be updated on a regular basis, with sufficient detail of the competency assessment, and dated. The residents are not able to self-medicate and all medicines are dispensed by the care staff. The medication administration records were up to date and correct but the separate list of medication for each service user was out of date and did not match the medication listed on the administration record, however, staff confirmed that they only dispense medication as listed on the medication record sheet. There are individual protocols for medicine that is given as and when needed (PRN) but some of these need more detail and information for staff as to when and why medication should be offered. Care staff also need to have access to an up to date directory of medication information, the current one is several years out of date. Although the medication is safely stored in a locked cupboard in the kitchen, the key to this cupboard is left out on view. In discussion with the manager and care staff, this was identified as a security risk and the key to the medication cupboard should be in a secure place or only accessible to a designated member of staff on each shift. The manager agreed that immediate action would be taken to address these issues. Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 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. 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. The home’s policies, procedures and practices ensure that residents are safeguarded from abuse. Procedures for responding to suspicion or evidence of abuse are robust. The home has a written complaints procedure. EVIDENCE: The home has a complaints procedure and although residents are not able to participate in any consultation about the service provided by the home the care managers who visit the home are in the process of setting up individual advocacy support for all of the residents to ensure that their choices and preferences are represented. Relatives explained that they would know how to make a complaint but had not needed to use this process. Since the last inspection Islecare have updated the policy and procedures for the protection of vulnerable adults and a copy of the policy is available to staff in the home. Adult protection awareness training for staff is ongoing. Reports received since the last inspection demonstrates that any concerns about the safety or well being of the residents are responded to promptly and appropriately. Overbrook DS0000012520.V320030.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing residents with a comfortable and homely place to live. However, the garden area could present a hazard to visually impaired residents and should be regularly checked and maintained. EVIDENCE: The inspector toured the building with the manager and noted all areas to be clean, tidy and free from unpleasant odours. Support workers undertake the domestic tasks; an arrangement that seems to work well in what is essentially a domestic style setting. There is a separate utility room where the laundry is carried out, away from food preparation and eating areas. The kitchen has been re-fitted since the last inspection and has sufficient storage and work space. The seal at the back of the sink is coming away and needs some repair. Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 Page 18 The home’s pre-inspection information confirmed that policies and procedures are in place for the control of infection and safe handling of any clinical waste. The premises generally are warm and comfortable with one bedroom on the ground floor and three on the first floor. The manager has recently looked at the feasibility of installing a stair lift but has been told that the stair well is not suitable. The manager will monitor the residents’ ability to continue using the stairs. There is level access from the sitting room to an enclosed garden at the rear, which is mainly laid to lawn and includes seating for use by the residents. At the front of the house there is a small parking area, trees and flowerbeds. The front garden needs some tidying to remove litter that has collected over the winter and the manager said she plans to arrange for the trees to be pruned. The manager also needs to ensure that the large back garden is kept free of hazards such as fallen fruit, long grass, overhanging branches to ensure that residents with a visual impairment can access the garden safely. Overbrook DS0000012520.V320030.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an experienced and effective staff team with sufficient numbers to support residents’ needs, most of the time. The use of agency staff must be monitored and recorded. Residents are protected by the home’s recruitment procedures and there is an ongoing programme of staff training and development. Formal staff supervision arrangements have lapsed and must be put in place. EVIDENCE: The staff rota confirms that there are always two members of staff on duty during the day and evening and one person sleeping in at night. The registered manager divides her time between Overbrook and another home that she also manages (a few miles away). The home does not employ any domestic staff and care staff do all of the household tasks. It was evident from observation and feedback that most of the time, there are sufficient staff numbers on duty. However, the home has recently found it difficult to cover Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 Page 20 staff sickness and holiday and on some occasions agency staff have covered shifts. In discussion with the manager concern was expressed by the inspector about leaving one person from an agency in charge of the home at night. The manager confirmed that she always makes sure that the agency staff are known to her but the manager must record that all agency staff are checked for recruitment checks and relevant experience and qualifications before they work in the home. It is not good practice for agency staff that do not know the residents, to be working alone in the home at night. This has only happened on one occasion and the manager confirmed that it would not happen again. Care staff employed in the home say that sometimes it is difficult to get staff cover for them to undertake planned training and if no cover is available they have to postpone their training. However, the manager explained that the training was arranged for another time. With only two care staff on duty, there are occasions when staff are limited in the time they have to spend with the residents or taking the residents out for visits or social outings. Sometimes this is because there is cleaning, shopping and cooking to cover; medication and management responsibilities, and sometimes the residents have varying transport needs and one person is required to drive the home’s vehicle. There is no flexibility in the staffing arrangements to cover any changes to the residents’ needs or wishes. Generally, the recruitment procedures operated by Islecare are thorough and robust. Records were available for one new member of staff and other records were made available on the second visit to the home and all were satisfactory. Islecare co-ordinate staff training centrally and there is a thorough programme of training for new staff and ongoing training in all areas of safe working practice for all staff. Out of the 10 members of staff, all but one have achieved at least the National Vocational Qualification level 2 in care, and all staff have done some of the units for the first level of the Learning Disability Framework qualification. Since the last inspection, training has also been offered on Downs Syndrome and Autism and all of the staff have covered training in basic first aid. Staff supervision arrangements need to be reviewed; because of staffing difficulties, the formal supervision of staff has not been happening. In discussion with the manager, she confirmed that this would be put into place and new supervision dates have been arranged for all of the staff. Overbrook DS0000012520.V320030.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. 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. Residents benefit from a well run home and the health, safety and welfare of the residents and staff are promoted and protected. However, the manager must take action on the outstanding requirement and also ensure that agency staff records and supervision arrangements are kept up to date. The Quality Assurance systems need to be developed to demonstrate the home’s commitment to improvement and development in the best interests of the residents. EVIDENCE: The registered manager has been in post for five years and is qualified and experienced. The manager is responsible for two care homes; Overbrook and Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 Page 22 another care home several miles away in Newport. The manager divides her working week between the two homes and is on call for some of the time ‘out of hours’. At the moment, the hours of the registered manager are not recorded on the staff rota and it is recommended that this be done in order to demonstrate the hours worked by the manager, and also so that care staff and residents know when the manager will be there. The manager confirmed that she would record her hours. When the registered manager is not there, a senior member of staff is in charge of the home. Because of staff absence over the last year, some of the recording systems and supervision arrangements have lapsed. These have been recorded in the report and discussed with the manager who confirmed that action would be taken. Islecare have their own internal quality audit process and in addition, a representative from Islecare carries out regular inspections of the home under Regulation 26 of the Care Homes Regulations 2001. The Quality Assurance process needs to be developed to ensure that the rights and best interests of the residents are represented by others involved in the service such as relatives, visitors, and health and social care professionals or independent advocates. This is happening informally and comments from relatives and care managers demonstrate that there is good communication between the care staff and others involved in the care of the residents. However, there is a reliance on verbal information and as demonstrated by the lack of specific information about the contract or terms and conditions of the service, misunderstandings do arise – such as the confusion last year about payment for the home’s vehicle. The requirement for information about specific terms and conditions to be made available to service user representatives has not been met and must be addressed. Arrangements in the home to promote safe working practice are good. Since the last inspection and following a cooker fire in the kitchen, the home was inspected for fire safety. The manager confirmed that all fire safety requirements were met within the required timescales. The manager confirmed that fire drills take place at least twice per year and inspection of the fire safety logbook found this to be up to date. The pre-inspection information supplied by the manager confirmed that all required checks on maintenance and equipment are up to date. Overbrook DS0000012520.V320030.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 3 2 N/A 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 Page 24 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 YA5 Regulation 5 (c) Requirement Each service user or their representative must have a contract or details of the terms and conditions of the services and facilities provided by the home. This is a repeat requirement and the previous timescale of 30/12/05 has not been met. Timescale for action 30/03/07 2. YA13 YA14 16(2)(m) 3. YA32 4. YA36 The registered manager must ensure that service users have access to suitable transport for all planned activities. 18(1)(a)(b) Agency or temporary staff employed in the home must be suitably qualified, competent and supervised and records maintained to this effect. 18(2) The registered manager must ensure that staff receive regular opportunities for formal supervision as part of their training and development. 28/02/07 28/02/07 28/02/07 Overbrook DS0000012520.V320030.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. 2. 3. Refer to Standard YA20 Good Practice Recommendations Review medication procedures to ensure that all records are current, storage of medication is secure, and records of staff competency in medication are dated and reviewed. The back garden should be free of any hazards for residents who have a visual impairment and the front and back garden should be kept neat and tidy. The Quality Assurance systems should be developed to demonstrate that the rights and interests of the service users underpin the monitoring and development of the service. YA24 YA39 Overbrook DS0000012520.V320030.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Overbrook DS0000012520.V320030.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. 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!