CARE HOME ADULTS 18-65
Rushall Road (6) 6 Rushall Road North Newnton Pewsey Wiltshire SN9 6TY Lead Inspector
Elaine Barber Unannounced Inspection 11th July 2006 13:05 Rushall Road (6) DS0000028106.V298466.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 Rushall Road (6) DS0000028106.V298466.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. Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Rushall Road (6) Address 6 Rushall Road North Newnton Pewsey Wiltshire SN9 6TY 01980 630478 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) Steven@StevenAbbott.wanadoo.co.uk Mrs Jane Abbott Mr Steven Abbott Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st March 2006 Brief Description of the Service: Valued Lives is a private organisation, which operates five care homes for adults with a learning disability. All are small establishments, intended to offer a normal domestic lifestyle. The main lead for the organisation is taken by one of the registered persons, Mrs Jane Abbott. She is supported by other senior colleagues, including family members. Each of the Valued Lives homes is situated in Pewsey, or nearby small villages. Pewsey itself offers a range of amenities. The market towns of Marlborough or Devizes are within 15 minutes’ drive. Or, slightly further afield, there are the larger centres of Salisbury and Swindon. The organisation has a number of vehicles used to transport service users, who contribute towards the costs of these. Most service users now cared for by the organisation have been with them for a number of years. Time may have been spent in more than one of the homes that Valued Lives operates. Valued Lives also operates the Activity, Opportunity & Development centre (AOD). This is a day care facility which most of the organisation’s service users access, for at least part of each week. They pay a small weekly sum towards this. The unit is attached to the home in Ball Road, Pewsey but a new building is being converted for the service. 6 Rushall Road, in North Newnton, cares for up to three people. The present occupants are all male. All have single rooms, on the first floor. There is also a bathroom. There is a shared sitting room, dining room and kitchen downstairs. There is an enclosed garden area at the back of the house. The fees range from £623 to £790. Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection included two unannounced visits to the home on 11th and 12th July 2006. During the visits information was gathered using: • • • Observation Discussion with staff Reading records. Other information and feedback about the home has been received and taken into account as part of this inspection: • • • The manager provided information prior to the inspection about the running of the home. The provider provided additional information after the visits to the home. Comment cards were received from two relatives and visitors. The judgements contained in this report have been made from all this evidence gathered during the inspection, including the visits. Feedback was given to the provider on 8th August 2006. What the service does well:
The people who lived at Rushall Road had been there for several years and had established routines. Each person had had their needs assessed over this time so that their needs and aspirations were met by the home. People’s assessed needs and personal goals were reflected in the individual plans. These were reviewed six monthly or when needs changed to ensure that needs and goals continued to be met. People made choices and decisions about their lives with assistance as needed. Recently people had chosen colours for rooms and carpets. They had a choice of activities. People were supported to take risks as part of an independent lifestyle. Risks of participating in day to day activities were assessed and unnecessary risks were minimised. People were provided with a range of activities and opportunities, offering them full engagement with their local community. They were able to maintain and develop appropriate relationships with family and friends. People’s individual lives had an appropriate balance between necessary routines, and individual choice. Staff supported people to make choices including the colours of their bedrooms, activities and menu planning. Staff used recipe cards from
Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 6 Waitrose to help people to choose meals for the menu. People were offered healthy, nutritious and enjoyable meals. Individual preferences about routines and assistance were recorded in the care plans. This ensured that people received personal support in ways that they preferred and needed. People had access to healthcare and had appointments with a range of health professionals. Their physical and emotional health needs were being met. The arrangements for managing and recording medication ensured people were protected. There was an appropriate complaints procedure and relatives were aware of how to complain. There was also a policy about abuse and information about the local multi-agency arrangements for investigation abuse. Staff had training about abuse awareness. This ensured that people were safeguarded by the home’s policies and procedures for complaints and protection. People were protected from abuse, neglect and self harm. 6 Rushall Road was situated in a row of houses on a main road through the Vale of Pewsey and was in keeping with other houses in the area. The home was generally in a good state of decoration and repair although some areas could be improved. The home was clean and hygienic. People were supported by an effective staff team, who were appropriately trained, competent and qualified to meet their needs. All the staff who worked in the home had a National Vocational Qualification. They also had a range of training. Refresher training and specialist training were also planned. Each member of staff had worked in the home for several years and was familiar with the people’s needs and wishes. There had been no new staff since the last inspection. A new manager had recently been registered for the service who was appropriately qualified to run the home. He was supported by the proprietor and other senior managers in the organisation so that people were benefiting from a well run home. A quality assurance system had been developed and views of people who used the service, their relatives and visiting professionals had been obtained. People’s views underpinned all self-monitoring, review and development by the home. There was a range of health and safety measures to ensure that the environment was safe for the people who lived there and the staff. People’s health, safety and welfare were promoted and protected. What has improved since the last inspection?
Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 7 Staff had started work on developing the care plans, which were reviewed six monthly or when needs changed. The review records were signed and dated so it was clear when the review had taken place and a review of the needs and care plan was required next. A recommendation was made at the previous inspection about appropriate consultation regarding the possible swap of bedrooms by two people. The people’s relatives and an occupational therapist were consulted. However, the reason for the swap changed and it did not take place. In response to another recommendation advice had also been sought from an occupational therapist about the risks to one person of using the stairs and landing. There was a requirement at the last inspection that a damaged area of flooring in the dining room must be repaired and replaced. A new carpet had been laid in the dining room to improve this area. Further work had been done to the quality assurance system. The views of people who used the service, relatives and professionals had been obtained and a report of the findings had been produced and areas for improvement and for the benefit of people had been identified. At the last inspection there was a manager who did not have a relevant qualification to ensure that the home was well run. Steve Abbott had been approved as the registered manager since the last inspection. He had a National Vocational Qualification at Level 4. What they could do better:
Work should continue to develop the content and presentation of care plans, and associated information. Care plans should be signed and dated to show when they were developed and by whom. The proprietors had identified areas in the home, which needed improvement for the benefit of people living there. This included redecoration of two of the bedrooms. They also planned to replace the carpet to the landing, stairs and living room. They were also considering replacing the kitchen cupboards, which were showing signs of wear and tear. The radiator covers were not painted and they would look more homely if they were painted. The proprietors planned to introduce Learning Disability Award Framework training for all staff. This will help to improve further the understanding of all staff about learning disability. Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 8 Further work needs to be done to complete the quality assurance process. The report about the findings of the surveys needs to be published by sending a copy to the Commission making copies available to people who use the service. 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. Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 9 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 Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area was good. This judgement was made from evidence gathered during the visit to the home. People had their needs assessed so that their needs and aspirations were met by the home. EVIDENCE: There have been no recent admissions to the home. All service users at Rushall Road have lived within Valued Lives for a number of years. They have therefore established their routines. There has also been continuity and stability in the staff team. Many have several years’ experience. This has given them a depth of knowledge regarding service users. Each person had their needs assessed over a period of years. Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 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 the following standard(s): 6,7,9 Quality in this outcome area was good. This judgement has been made from evidence gathered during the visit to the home. People’s assessed needs and personal goals were reflected in the individual plans so that these needs and goals could be met. People made choices and decisions about their lives with assistance as needed. People were supported to take risks as part of an independent lifestyle. Unnecessary risks were minimised. EVIDENCE: Each person had a detailed care plan. None of these were signed and dated to show when they were developed and by whom. There was a recommendation at the previous inspection that all service user documentation should be clearly signed and dated. Care plans were reviewed approximately every six months. One person’s plan had an extra review because of a change in needs. The
Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 12 reviews were signed and dated. Each person also had a plan of goals they wished to achieve. These were also reviewed. There were examples of choice and decision making in the care plans and ways in which people were supported to make choices. Examples of when people made choices and decisions were also recorded in the daily records. Two staff members described how people made choices of colours for rooms and carpets. The records showed that there was a choice of activities. New opportunities were identified in the goal plans. At the previous inspection staff were considering swapping the bedrooms of two people who lived in the home. A recommendation was made that there should be evidence of appropriate consultation regarding the possible swap of bedrooms by these two people. The members of staff reported that the people’s relatives and an occupational therapist was consulted. However, the reason for the swap changed and it did not take place. Each person had risk assessments for all aspects of daily living. The assessments also included the action to be taken to reduce risks. There had been a situation at the last inspection of one person being at risk because they got up in the night and passed the top of the stairs. A recommendation was made that appropriate professional advice should be obtained on ways to minimise risks associated with service users accessing the stairs and landing. The members of staff reported that the occupational therapist had been consulted but they did not conduct an assessment because the person stopped getting up. Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 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 the following standard(s): 12. 13, 15, 16, 17 Quality in the outcome area is good. This judgement was made from evidence gathered during the visit to the home. People were provided with a range of activities and opportunities, offering them full engagement with their local community. People were able to maintain and develop appropriate relationships with family and friends. People’s individual lives had an appropriate balance between necessary routines, and individual choice. People were offered healthy, nutritious and enjoyable meals, in line with individual needs and preferences. EVIDENCE: A new day service was being developed within the organisation and was due to opened soon. The member of staff on duty said that there is a plan for the
Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 14 people who live in the home to pursue day time activities at the service once it is open. In the meantime people were going out with staff on a daily basis. The member of staff on duty gave examples of trips to the shops, to Devizes, Fairford Air Tattoo, an event for people with learning disabilities at Blandford, going bowling and to the pub. The daily records and goal plans showed that people went to the library, swimming, bowling, shopping, café, the cinema and the pub. People also had long weekends at a caravan owned by the organisation, they had been on a canal boat trip, they went to church once a month and members of the church visited them once a month. The records showed when people had outings and when they did domestic chores with support. They also showed that there was an appropriate balance between the two. One of the relatives who completed a comment card said that there were plenty of activities. Arrangements for contact with families and friends were recorded in the care plans. The member of staff said that relatives visit the home and phone and staff support people to visit their relatives and have outings with relatives. Two relatives commented that they were welcome in the home any time. One said that they could telephone at any time. They also said that staff brought their relative to visit them every four weeks and collected them afterwards. People had friends from some of the other houses in the organisation whom they saw regularly. They also met friends at a social club, which they visited once a fortnight. The members of staff both reported that they used recipe cards from Waitrose to help people to choose meals for the menu. All three people had been tested for food intolerances and the meals took account of these. A dietician had advised about the diet provided. Herbal teas and fruit juices were offered. High quality ingredients were provided. Lunch on the day of inspection was warm bacon salad, which was modified to account for individual dietary preferences. The member of staff ate with the people who were observed to be enjoying the food. Rushall Road (6) DS0000028106.V298466.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, 20 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to the home and from relatives’ comment cards. People received personal support in ways that they preferred and needed. Their physical and emotional health needs were being met. The arrangements for managing and recording medication ensured people were protected. Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 16 EVIDENCE: People’s preferred routines were identified in their care plans. The ways in which they liked to be supported were recorded in detail. Details about health care needs were also recorded in the care plans. The daily records showed that people had appointments with health care professionals. Dates of appointments and the outcome of the visit were recorded. People had access to the GP, district nurse, continence advisor, podiatrist, optician and dentist. There had also been regular input from an occupational therapist, to give advice on suitable equipment and techniques to support people with decreased mobility and risks associated with using the landing ad stairs. One person’s relative commented that staff had been very helpful over a health problem and they had medical tests done and obtained a wheelchair. Both relatives who commented said that they were satisfied with the care provided. There was a policy about medication. Each person had a record of the medicines they took recorded in their personal notes. There was also a description of how people consented to take their medication. Medication was reviewed by the GP. Each person had a list of homely remedies, which was agreed by the GP and there was guidance about as required medication. Appropriate records were kept when medication was administered and there was a booking in and out book for medication received into the home and returned to the pharmacist. All staff had training about medication, including special methods of administration and this was reviewed annually. Rushall Road (6) DS0000028106.V298466.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, 23 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visits to the home and from relatives’ comment cards. Service users are safeguarded by the home’s policies and procedures for complaints and protection. Service users are protected from abuse, neglect and self harm. EVIDENCE: There was an appropriate complaints procedure. There had been no complaints since the last inspection. The two relatives who completed comment cards were aware of the home’s complaints procedure. There was a policy about abuse prevention. There was information about the ‘No secrets’ guidance. Each member of staff had a copy of a leaflet about the local multi-agency adult protection procedures. All four members of staff had been on a course about abuse awareness. There was also video training and guidelines about dealing with allegations of abuse. There had been no allegations of abuse. The staff managed people’s personal money and appropriate records were kept of all transactions. Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 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 the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the visit to the home. People generally lived in a comfortable and clean environment, suitable to their needs. There were plans to improve some areas. EVIDENCE: 6 Rushall Road, North Newnton is situated in a row of houses on a main road through the Vale of Pewsey. There are views of the surrounding countryside. Amenities in the immediate local area are limited. The nearest large centre is the village of Pewsey itself. This is approximately three miles away. The home was generally in a good state of decoration and repair apart from one of the bedrooms. This had some peeling wall paper and there was a plan to redecorate it and one of the other bedrooms. The radiators were covered but the covers had not yet been painted. A step from the kitchen into the dining room, and part of the adjacent carpet were identified at the last inspection as in need of attention because of damage
Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 19 caused by the home’s dog. A new carpet had been laid in the dining room to improve this. A new carpet was also planned for the hall, stairs, landing and living room. The kitchen cupboards were showing signs of wear and tear. The member of staff said that the proprietors were considering replacing the cupboards. The home appeared clean and hygienic in all areas seen at this unannounced inspection. There was a washing machine in the kitchen and a tumble drier in the garage. A member of staff reported that people bring their own washing downstairs and do their washing with varying degrees of help from staff. During the inspection one person was seen putting their washing into the tumble drier and taking it out when it was dry. Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 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 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 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to the home and from comment cards. People were supported by an effective staff team, who were appropriately trained, competent and qualified to meet their needs. People were protected by the home’s recruitment practices. EVIDENCE: Each home within Valued Lives had some staff specifically allocated to it. Cover was then made up by other staff, who worked in more than one setting. The owner’s aim was to employ sufficient people so that, even if they were one staff member down, there were still enough to cover all the organisation’s services without needing to rely on external agencies. Rushall Road had three staff mainly allocated to it. The home aimed to keep continuity of staff, to minimise any disruption that might unsettle people who lived in the home. There were three regular staff and one person covered holidays and sickness. There was always at least one person on duty. This increased to two at busy times, and to enable people to access opportunities outside the home. At nights, one person slept in. An on-call manager was
Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 21 available if required. Both relatives who completed comment cards said that there were always sufficient staff on duty. All the staff had worked in the home for several years and were familiar with people’s needs. There had been no new staff since the previous inspection when the standard about recruitment was met. All of the four staff who worked in the home had a National Vocational Qualification. One had NVQ level 2, two had NVQ Level 3 and one had NVQ level 4. Staff had a range of training including health and safety, food hygiene, first aid, medication, including special methods of administration, and abuse awareness. Refresher training was planned in November for health and safety, food hygiene, first aid and administration of medicines by special methods. The owner reported that they also planned to introduce Learning Disability Award Framework training for all staff. Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to the home and from information received from the proprietor. People were benefiting from a well run home. People’s views underpinned all self-monitoring, review and development by the home although the report about these views needs to be published. People’s health, safety and welfare were promoted and protected by the health and safety measures. EVIDENCE: At the last inspection it was noted that the manager did not have an appropriate qualification and was not intending to obtain one. There was a requirement that the manager must be appropriately qualified. This
Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 23 requirement had been met. Steve Abbott had been approved as the registered manager since the last inspection. He had a National Vocational Qualification at Level 4. The registered person for Valued Lives is Mrs Jane Abbott. She has lengthy experience of working with people with learning disability, and has owned and operated her own services for many years. She is supported by other senior staff within the organisation. Together, they oversee all five services currently run by Valued Lives. Since the last inspection the registered person and registered manager had been working on their quality assurance for the service. The quality assurance framework was based on the systems in the house including policies and procedures, care plans, records and staffing. A consultant had provided advice and guidance about quality assurance. The views of people who used the service, relatives and visiting professionals had been collected. These had been collated into a quality assurance report for the whole service covering five homes. There was also a draft review report of the previous three years. Areas for improvement were identified. A copy of this report now needs to be sent to the Commission and made available to all people who use the service. There was a health and safety policy to comply with the relevant regulations. A number of general risk assessments and safe working procedures had been recorded. There were also individual risk assessments. There were arrangements for the training of staff in moving and handling, fire safety, first aid and food hygiene. A monthly ‘hazard’ inspection of the home was carried out. Hot water temperature regulators had been fitted to the taps. There were COSHH assessments, equipment was regularly serviced and portable appliances were tested annually. There was a fire risk assessment and records of fire safety checks. The fire officer visited in September 2004 and was satisfied with the risk assessment. He advised that the fire risk assessment should be amended if there were any changes to the fire safety measures. Staff reported that there had been none. The radiators upstairs were covered. Those in the living room and dining room were not. The member of staff reported that this was because the risks were lower downstairs as people were always observed by staff when they were in the living room and dining room. Information was available about what to do in the event of a heat wave. Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 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 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 4 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 X 3 X X 3 X Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 25 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. 3. Standard YA39 Regulation 24 Requirement The registered person must supply to the Commission a copy of the report about the quality assurance survey and make a copy of the report available to service users. Timescale for action 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. Refer to Standard YA6 Good Practice Recommendations Work should continue to develop the content and presentation of care plans, and associated information. Care plans should be signed and dated to show when they were developed and by whom. The radiator covers should be repainted to make them look more homely. The bedroom with the peeling wallpaper should be redecorated. The kitchen cupboards should be repaired and repainted or replaced. 2. YA24 Rushall Road (6) DS0000028106.V298466.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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