Inspection on 07/07/05 for REACH Bierton Road

This inspection was carried out on 7th July 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

REACH Bierton Road 07/07/08

REACH Bierton Road 13/07/07

REACH Bierton Road 20/12/06

REACH Bierton Road 23/05/06

REACH Bierton Road 02/12/05

REACH Bierton Road 05/01/05

REACH Bierton Road 15/07/04

REACH Bierton Road 20/02/04

Similar services:

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Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Bierton Road (20-22) Aylesbury Bucks HP20 1EJ Lead Inspector Mike Murphy Announced 7th July 2005 09:30 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 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 Stationary 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. Bierton Road (20-22) Version 1.10 Page 3 SERVICE INFORMATION Name of service Bierton Road (20-22) Address Aylesbury, Bucks, HP20 1EJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01296 429586 REACH Limited Mrs Nasrin Saeedi, Mr Abbas Shams Miss Amanda Follette Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Bierton Road (20-22) Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2005 Brief Description of the Service: 20-22 Bierton Road, Aylesbury, is a care home providing residential care to eight adults with learning disabilities. The home is a conversion of two mid-terraced house.The service is managed by Rehabilitation Education and Community Homes Limited (REACH), an organisation specialising in residential care for adults with learning disabilities. The home is located about half a mile from Aylesbury town centre, convenient for the facilities of the town, the specialist facilities of Manor House Hospital which is across the road and public transport. All of the home’s bedrooms are single. None have en-suite facilities. Bierton Road (20-22) Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted by one inspector on Thursday 7 July 2005. The inspection started at 10.00 hours and finished that day at 18.15 hours. The inspection resumed on Friday 15 July at 10.00 hours. The inspection was disrupted to a certain extent on the first day by a developing situation in London. The inspector, the registered manager and the responsible individual agreed to adjourn at 18.15 hours and resume one week later on the 15 July 2005. On the second day three residents and staff were on holiday in Scarborough. The inspection consisted of discussions with the registered manager and responsible individual, with residents and staff, consideration of a preinspection questionnaire and comment cards submitted by relatives in advance of the inspection, residents records were examined, policy documents and notices were perused, two residents cash balance were checked, the inspector walked around the home, spent time in the lounge with residents, and generally observed activity. The overall situation in the home was settled. A new resident had been admitted since the last inspection and was settling in well. Residents were getting on well together. Staff vacancies were leading to some acute pressure but new staff had been appointed and were due to start in the autumn. The organisation was reviewing its format for care planning and was on the point of introducing ‘person centred planning’ (PCP). This will facilitate some rationalisation of existing documentation. The overall standard of care planning was found to be satisfactory. Residents participate in a range of activities and on the second day three residents were on holiday in Scarborough. The home is a conversion of two older style terraced houses and has both the advantages and disadvantages of properties. It is well located for the town centre, its style is in keeping with other houses in the locality and the size of the garden seems to suit the residents. On the other hand the interior requires a constant programme of refurbishment, space is at a premium and health & safety aspects of the environment require constant monitoring. Overall however, in spite of staffing pressures which are affecting some aspects of care and some weaknesses in health & safety systems, this home continues to provide good support to residents. Bierton Road (20-22) Version 1.10 Page 6 What the service does well: 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or Bierton Road (20-22) Version 1.10 Page 7 by contacting your local CSCI office. Bierton Road (20-22) Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Bierton Road (20-22) Version 1.10 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 standard(s) 2, 3,4 Prospective residents are carefully assessed prior to admission to ensure that the home can meet the person’s needs. The admission of new residents is carried out over time to ensure that the new resident feels that the move is right and that the home can meet his or her needs, and that existing residents are able to accommodate the new person. EVIDENCE: The home had admitted one new resident since the last inspection. The home had had the vacancy for some time because of the importance of obtaining a match between a prospective residents needs and what the service can offer, and between the new resident and existing residents. The new residents file was examined, the registered manager outlined the process of assessment and the opinion of the resident was sought on how she felt the move had gone. The resident seemed very happy, said that everyone had been welcoming and that she was now settled in the home. At the point of referral the prospective resident’s care manager visited the home. The manager and another member of staff then visited the person in hospital. The responsible individual and a senior manager then conducted a fuller assessment of the person. It was decided that the home could meet her needs and a proposal was made to the care manager. The care manager and the home then arranged a series of visits for the person to see the home and Bierton Road (20-22) Version 1.10 Page 10 to get to know other residents and staff. A nurse from the hospital also visited the home to talk to staff and support the person during the transition from hospital to the home. The process outlined above is thorough and the prospective resident did not appear to have been put under any pressure to make an early decision. Appropriately, the prospective resident’s welfare – and that of existing residents – appears to have been of prime concern. Notes made during this period and other information was examined. The registered manager had access to relevant medical and social services information and a copy of the most recent Community Care Act assessment was on file. The standard of the home’s own notes is variable and while the content seems appropriate to managing any risks involved in this admission it is also important that such documents are fully completed. For example guidelines from the manager to staff are unsigned and undated. A ‘Contract’ seemed one sided in that it set out the rules, boundaries and expectations with which the resident was expected to comply without setting out what the home would offer in return. The resident was required to sign the ‘contract’ although the person’s capacity to fully understand it may have been impaired. An offer of an advocate was not made. The organisations own assessment form was not fully completed. The home liaises with healthcare and other agencies in the community in meeting residents needs. Residents have access to advocacy as required. REACH maintains an ongoing training programme with the aim of ensuring that staff have the necessary skills to meet residents needs. Bierton Road (20-22) Version 1.10 Page 11 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 standard(s) 6,7,9 The needs of residents are assessed and recorded and provide a basis for the formulation of a plan of care. Care plans are comprehensive and detailed and encompass a wide range of activities which leads to residents needs being met. The structure of care plans include a variety of documents the inclusion of which can impede efficient recording and communication of information. Staff support residents through a range of activities which leads to residents being involved in matters relating to their own care and those of the house as a whole. Policy and procedures for the management of residents monies aim to ensure that such monies are securely managed which minimises the risk of loss to residents while not imposing undue restrictions on residents. EVIDENCE: Information relevant to care plans may be found in five documents: the resident’s ‘care plan’, the resident’s ‘personal diary’, the individual’s contract file, the observation book, and the handover book. Contemporaneous records may be found in each of these documents. Such a method can impede efficient Bierton Road (20-22) Version 1.10 Page 12 recording and communication of information. The system has been reviewed by REACH and the home will be introducing ‘person centred planning’ (PCP) over the latter half 2005. REACH has yet to agree the final format of its PCP care plans but it is expected that some rationalisation of documentation will take place. The introduction of the new system is to be accompanied by a programme of staff training in the approach. Despite the diversity of documents care plans in the home were comprehensive and detailed. Apart from a photograph and basic information on the resident, care plans examined had comprehensive assessments of need and risk assessments, excellent guidelines for personal care, relevant healthcare information and relevant reports from other organisations. Multiagency reviews are held once a year but may occur more often where required. Two observation books were examined. These are used to record episodes of problem behaviours. Records tended to be limited to a brief description of the behaviour without reference to the wider context at the time of the occurrence, its content, antecedents, duration or consequences. Staff support residents in making decisions. Residents ability to fully understand information can vary and an advocate from Aylesbury Vale Advocates regularly visits the home to support to residents as required. Limitations on service users are decided after risk assessment and in the interests of individual safety and welfare. Residents and staff are constantly exchanging information and residents are consulted on menus and social events. This is a relatively small home of eight residents and staff provide feedback informally to residents on their participation in the life of the home. Staff were observed to communicate appropriate positive comments to residents over the course of the inspection. A house meeting is held once a month and includes discussion on subjects such as food, outings, social events or matters of concern. REACH acts as an appointee for six residents, a Nationwide building society account being held for each. Home staff do not act in any formal capacity with regard to residents finances. Systems for assessing individual risk are well developed and cover a wide range of activities. Records are retained in individual care plans. The home is required to conform to REACH policy and practice with regard to unexplained absences by service users. This is available in the staff office. Bierton Road (20-22) Version 1.10 Page 13 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 standard(s) Standards in this section were not assessed on this inspection EVIDENCE: Bierton Road (20-22) Version 1.10 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 standard(s) 18 & 19 Resident’s preferences for care are summarised in a guidelines document and expressed in a style which the resident might use. This means that care is more likely to be provided in a way which meets the resident’s preferences. All residents are registered with a GP and the home liaises with other health, social and educational services in the community which increases the chances individual needs being met. EVIDENCE: Residents preferences for care are summarised in the document ‘guidelines for personal care’ which forms part of the care plan. This is an easy to read summary written in the first person. On this and earlier inspections it has been observed that residents individual wishes are taken account of by staff and that undue pressure is not imposed on residents to participate in activities. Personal care is carried out in the privacy of bathrooms or bedrooms. Additional support is provided by health and social care services and the home’s proximity to Manor House hospital where NHS services for people with learning disability are centred has been found to be advantageous on occasions. The home has regular contact with an advocate from Aylesbury Vale Advocates. Bierton Road (20-22) Version 1.10 Page 15 All residents are registered with the nearby Elmhurst Surgery practice in Aylesbury and have at a minimum an annual health check. Specialist healthcare (learning disability, psychiatry and psychology) is provided by the CLDT and other NHS services based at Manor House Hospital. Other healthcare needs are accessed through the NHS. Bierton Road (20-22) Version 1.10 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 standard(s) 22,23 The home’s policy on abuse is available in conventional and WIDGET formats which means that residents, including those familiar with WIDGET, can familiarise themselves with the organisation’s procedures. While the organisation’s policy and procedures on abuse are comprehensive they do not include some local contact information and in consequence a person wishing to report abuse may not be aware of organisations in the local area with responsibility for investigating allegations of abuse. Some residents have regular contact with an advocate which provides both support and advice to the residents and introduces an element of informed independent observation to the home. EVIDENCE: The home is required to conform to REACH policy on abuse. This is outlined a document entitled ‘Raising Awareness of Abuse’ which is available in conventional and WIDGET format (a good practice in settings where staff and residents are familiar with WIDGET). The policy was issued in 2002 and while it is a thorough policy it would now benefit from updating in the light of changes since then and a cross reference to REACH policy on Whistleblowing would also be helpful. The whistleblowing policy reflects an open approach on the part of the organisation but it too would benefit from review and updating. While it includes the contact number for the organisation Public Concern at Work (PcaW), an independent organisation on Whistleblowing, it does not include contact numbers for Bucks Social Services Careline or that of CSCI. Each resident is given a card with advice on safety. Bierton Road (20-22) Version 1.10 Page 17 The manager attended training on POVA in September 2004 but has not been able to participate in further training because of staff shortages in the home. Two staff attended POVA training in May 2005. The home has a copy of the Buckinghamshire Inter-Agency Guidelines on vulnerable adults and was awaiting information on the outcome of the most recent policy review in Bucks. With the anticipated easing of staffing pressures in the autumn of 2005 the registered manager, in conjunction with REACH head office, will need to address training on abuse and the protection of vulnerable adults. Some residents have regular contact with Aylesbury Vale Advocates. The home has a complaints policy and procedure which was last reviewed in 2002. No complaints have been received since the last inspection. A copy of the complaints procedure on display was inaccurate in stating that reference to CSCI may occur at the end of the internal complaints procedure – a complainant may refer a complaint at any stage. The home has a copy of REACH ‘Guidelines for Practice’ on dealing with aggression. This was last reviewed in 2002. Staff training has been affected by staffing pressures and needs to be readdressed when these ease in the autumn. The home’s policies and procedures for managing residents monies appear thorough. Income support is paid into an account. The directors of the company act as appointees for six residents. The manager is authorised to draw cash out for residents. Small amounts of cash are retained in a safe. The amounts are checked on Regulation 26 visits by a director and quarterly by a finance administrator. The balances for two residents were checked on this inspection and were found to be satisfactory. Bierton Road (20-22) Version 1.10 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,27,28,30 The home is conveniently located a short distance from Aylesbury town centre and from Manor House hospital which means that residents can enjoy both the amenities of the town and the facilities of the hospital as required. The quality of the accommodation is generally good and provides a comfortable environment for residents. Hot water temperatures in the kitchen and laundry room are not regulated and some household cleaning materials are not locked away, both of which expose vulnerable residents to harm. EVIDENCE: The home comprises two mid terraced houses converted to form one home. The home is quite well located for Aylesbury town centre and the amenities of Manor House hospital, which is directly across the road. There are eight single bedrooms. None of the bedrooms have en suite facilities. One bedroom is on the ground floor. Room sizes vary. The ground floor consists of one bedroom, the lounge, dining room, kitchen, office, laundry room, a seating area which can be used for small meetings, and hallways. Although some wheelchair Bierton Road (20-22) Version 1.10 Page 19 access is possible on the ground floor negotiating rooms and hallways would not be straightforward. Other bedrooms are located on the first floor. The lift is not in use. There are sufficient bathrooms and WCs. The quality of the accommodation varies but some redecoration is carried out over the course of the year and since the last announced inspection three bedrooms have been repainted and two bathrooms painted and retiled. The rear garden is enclosed on three sides by wooden fencing. The garden is mainly lawn but one resident has developed a small flowerbed on one border. Radiators are not covered and must be individually risk assessed. New flooring has been laid in the dining room since the last announced inspection. The kitchen was clean and tidy. The temperature of the hot water in the unregulated kitchen outlet was tested at 750 Celsius – an unacceptable temperature in an area to which vulnerable people have access. The danger associated with this tap has been referred to on a previous inspection, and although the responsible individual who was present on this occasion took immediate action in requesting urgent attention by maintenance staff the following day, the risk will remain as long as this outlet is unregulated. The hot water needs to be at a temperature which is hot enough to wash dishes but not so hot as to pose a hazard to vulnerable people. The registered manager has sought the advice of the environmental health officer and REACH should now install equipment which ensures that the hot water at this outlet cannot reach the temperature found on this inspection. Some cleaning materials had not been locked away when not in use by staff. The refrigerators and freezer in the outhouse were in order and temperatures were recorded. The laundry room was clean and tidy. The floor surface appeared impermeable to water. The temperature of the hot water was tested at 740 Celsius. Some cleaning materials had been left out. The room was checked again on the second day of the inspection where it appeared that the washing machine was leaking. Vinyl gloves and washing powder had been left on the window sill. The hot water temperature was tested at 350 Celsius. This room is not locked and as such is a hazard to vulnerable people when staff are not present. The home is subject to REACH policy on the control of infection. This was last reviewed in 2002. Staff have not recently had training on control of infection. There are sufficient hand washing facilities around the home and paper hand towels are available in wc’s and kitchen. Given the nature of work carried out there it would be useful if a supply of paper hand towels was also provided by the hand washing sink in the laundry. Bierton Road (20-22) Version 1.10 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35,36 The home was experiencing an acute shortage of care staff which, although covered by relief staff familiar with residents, has a potential adverse effect on continuity of care, the range of opportunities for support in one to one activities, and pressure on permanent staff. Staff recruitment procedures are generally satisfactory but one employee recruited since the last announced inspection did not have a POVA first check before starting work under supervision. This exposes residents to risk. REACH offer a range of training opportunities for staff which improve the quality of care to residents through increased staff knowledge, skills and motivation. EVIDENCE: The timing of this inspection coincided with a period of acute staffing pressures in the home. Over half of the staff were designated ‘relief support’ drawn from an internal staff pool. Many relief staff are regularly rostered to work in the home and are familiar with residents and the home’s routine. REACH had recently recruited care staff from Poland and four were due to commence work in the autumn. The shortage of permanent staff was affecting a number of aspects including staff training, the frequency of personal staff supervision, in requiring the manager to cover shifts which reduced the amount of time Bierton Road (20-22) Version 1.10 Page 21 available for management work, and some restriction on activities with residents (for example on the range of activities requiring one to one support). The responsible individual and the manager were optimistic that these pressures would ease when new staff started in the autumn of 2005. General and specialist healthcare is accessed through residents GPs or the CLDT. Recruitment in the home is subject to REACH’s policies and procedures. Applicants are required to complete an application form. Two written references and an enhanced CRB are required. The file of one member of staff appointed since the last announced inspection was examined. The recruitment process was in order with the exception of evidence of a POVA first check being carried out before the person started work and in advance of an enhanced CRB certificate. Possible reasons for this omission on this occasion were discussed with the registered manager and via telephone with the head office. REACH maintains a training programme at induction, foundation and refresher levels. The pressures on staffing appeared to be having an effect on the ability of staff in this home to attend some training events. However in May 2005 staff attended training in ‘crisis intervention’, ‘POVA’ and ‘Dementia’; in June and July 2005 staff attended ‘crisis intervention’ and ‘first aid’. Staff have attended ‘PCP’ training and all staff have now had training in first aid. The registered mananger said that ‘planned or identified’ training included moving & handling, diabetes, equal opportunities, food hygiene and NVQ training. Reach has a policy on supervision and aims to offer personal supervision to staff on a monthly basis. Pressures on staff had had an effect on the home’s ability to meet this but the registered manager said that staff were receiving supervison every two months (which conforms to this standard). REACH has a well structured appraisal structure and the appraisal is held close to the anniversary date of appointment. The registered manager is appraised by the service manager. Staff have access to the organisation’s grievance and disciplinary procedures. Bierton Road (20-22) Version 1.10 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39,42 The home participates in the organisations quality assurance activities which are designed to ensure that the service meets the needs and expectations of residents and other stakeholders. Assessed performance in relation to health and safety practice was found uneven which may increase risk to residents, staff and visitors. EVIDENCE: Reach conducts an annual audit of stakeholders. The results of the 2005 audit were not yet available at the time of this inspection. A summary of the results are sent to respondents after having being considered by managers. REACH holds an internal management conference aimed according to the responsible individual at enhancing performance and working constructively with partners. REACH regularly submits detailed regulation 26 reports on the home. Although there was not a formal development plan available at the time of this inspection, two significant developments over the next six months or so are the introduction of ‘person centred planning’ (PCP) and ongoing refurbishment Bierton Road (20-22) Version 1.10 Page 23 of the home. An annual multi-agency review is held for each service user. Consultation with residents takes place through monthly house meetings. The home responds well to CSCI requirements and recommendations. The organisation has a process for reviewing and updating policies and procedures but evidence from this inspection in relation to some policies may indicate a need to review its effectiveness. The organisation expects to have additional management capacity to support homes in the autumn of 2005. The home is required to conform to the organisation’s extensive health & safety policies and procedures. REACH engages the services of Peninsula Health & Safety consultancy. Consultants conducted an audit of the home in May 2005 and the report was made available for inspection. The home was inspected by the Fire Authority in May 2005 and the inspecting officer found ‘…that all Fire Safety matters were considered satisfactory’ (report to CSCI dated 16 May 2005 refers). Fire awareness training for new staff is conducted in the home and is centred on a training video. This was last carried out in 2003 and should be repeated. A fire drill was carried out in July 2005 but the names of residents participating was not recorded. This is recommended. Emergency lighting and fire points were checked by engineers in June 2005. The office door is currently closed for fire safety purposes but this can impede office functioning and it is recommended that the registered seek the advice of the the fire service with regard to appropriate means of retaining the door in the open position while conforming to fire safety measures. All regular staff have now received training in first aid. First aid boxes were examined and need to be replaced. In deciding the contents the registered manager should take into account guidance from the Health & Safety Executive. Accidents records were examined. Update training in food hygiene is thought to be overdue. The home has not received a visit from an environmental health officer since 2001. PAT and electrical wiring certificates were in order. The temperature of the hot water in unregulated outlets in the laundry and kitchen (tested at 740 Celsius) has been referred to above and must be attended to. The laundry room does not have a lock and gloves and cleaning chemicals were left on the window. The registered manager said that Thames Valley Water had tested for Legionella but a report was not available for this inspection. Some windows on the first floor do not have restrictors fitted but on examination did have a degree of restriction and do not pose an immediate risk. Overall compliance with this standard on this inspection was found to be uneven. The appointment of new staff in the autumn presents the registered manager with an opportunity to review staff training, housekeeping (in relation to health & safety) and monitoring at all levels, and in liaison with senior managers to ensure that technical systems (obtaining specialist advice as required) are effectively maintaining a safe environment. Bierton Road (20-22) Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 3 3 x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 3 3 x 2 Standard No 11 12 13 14 15 Bierton Road (20-22) x x x x x Standard No 31 32 33 34 35 36 Score x x 2 1 2 3 Version 1.10 Page 25 16 17 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x Bierton Road (20-22) Version 1.10 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 42 Regulation 13 (4)(a) Requirement The registered manager is required to ensure that the temperature of the hot water in areas to which service users have access does not pose a hazard The registered manager is required to ensure that staff are not appointed before a POVA first check has been carried out in advance of an enhanced criminal record certificate The registered manager is required to ensure that staff appointed following a successful POVA first check are effectively supervised until an enhanced criminal records certificate is received The registered manager is required to ensure that cleaning and other materials which pose a hazard to vulnerable residents are locked away after use. Timescale for action 15 July 2005 2. 34 19 15 July 2005 3. 34 19 15 July 2005 4. 43 13(4)(a) 15 July 2005 Bierton Road (20-22) Version 1.10 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. Refer to Standard 22 Good Practice Recommendations It is recommended that the registered manager in liaison with the responsible individual review and update the homes documentation relating to the protection of vulnerable adults 2. Bierton Road (20-22) Version 1.10 Page 28 Commission for Social Care Inspection 8 Bell Business Park Smeaton Close Aylesbury Buckinghamshire HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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