Inspection on 17/08/05 for Sambourne Road (58)

This inspection was carried out on 17th August 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sambourne Road (58) 27/06/07

Sambourne Road (58) 13/01/06

Sambourne Road (58) 05/02/05

Sambourne Road (58) 06/09/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Sambourne Road (58) 58 Sambourne Road Warminster Wiltshire BA12 8LE Lead Inspector Tim Goadby Unannounced 17 August 2005 th 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. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sambourne Road (58) Address 58 Sambourne Road Warminster Wiltshire BA12 8LE 01985 217147 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) Royal Mencap (Housing & Support Services) Mencap National Centre Mr Byron Nadgie 6 Care Home Category(ies) of LD Learning Disability (6) registration, with number LD(E) Learning Disability - over 65 (1) of places PD Physical Disability - (1) Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users who may be accommodated at any one time is 6. 2. Only the one, named, female service user with a learning disability referred to in the application dated 9th March 2004 may be aged 65 years and over. 3. Not more than 1 male service user in the age range 18-64 years with a physical disability may be accommodated at any time. Date of last inspection 5th February 2005 Brief Description of the Service: 58 Sambourne Road provides care and accommodation for up to 6 adults with a learning disability. The home is also registered to care for 1 person with physical disability. The service is operated by Mencap, a national voluntary organisation in the learning disability field. The property is a detached house in a residential area of Warminster. It is within walking distance of the towns amenities. There are also good public transport links. The building dates originally from Victorian times, and has been extended at one side. All service users have single bedrooms, one of which is downstairs. Each bedroom has a hand basin, but there are no other en-suite facilities. There is a shower on the ground floor, and a bathroom upstairs. There is also another separate toilet, off the half landing on the staircase. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in August 2005. A total of 4.5 hours were spent in the home. A follow up phone call was made the next day, and the home sent through some information which had not been located during the visit. The following inspection methods have been used in the production of this report: indirect observation; sampling of records, with case tracking; discussions with service users and staff. What the service does well: What has improved since the last inspection? There were no requirements or good practice recommendations set at the previous inspection, in February 2005. This indicates that the home was performing well, although not all standards were assessed at that visit. Continuing progress has been made in some key areas. The drive to promote individual responsibility and independence for service users has included a new step of giving each person an amount of housekeeping money each week. They then retain responsibility for how this Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 6 is spent, and for the collection of relevant receipts that will be needed for records. The involvement of service users in the planning of their own care has also continued to develop. The implementation of ‘person centred planning’ is well underway. Service users are fully engaged in developing their own folders for this exercise. Staff are also to receive further relevant training. The home’s registered manager, Mr Byron Nadgie, has returned to the service following a period of secondment elsewhere within Mencap. Whilst there were suitable temporary arrangements in place to cover his absence, the home should benefit from the greater stability of having its allocated manager back in position. 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. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 3 Prospective service users have information to assist their choice about where to live. These documents would benefit from further attention, to ensure that they include all relevant details. The service meets the needs and aspirations of its users. EVIDENCE: The service has a Statement of Purpose, and Service User Guide. These have recently been updated, and copies of the revised versions supplied to the CSCI. Consideration of the documents before the inspection identified that some further attention is needed, to ensure that they meet all relevant criteria fully. The Statement could give greater information about organisational structure, by showing how Sambourne Road is overseen within Mencap. Fire precautions and other emergency procedures are not specified in any detail. The copy of the Guide provided to the Commission did not include service users’ views of the home. Contact details for the CSCI did not have the correct up to date name of the organisation. Nor was there any mention about the CSCI’s inspection reports on the service, and how to access these. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 9 The home has an established group of 5 residents. There is 1 service user vacancy at present. This was filled briefly earlier in the year, but that placement did not work out. There were no prospective service users under consideration at the time of this inspection. As the current group consists of 3 males and 2 females, service users have expressed a preference for another female, to even up the balance. Sambourne Road has a philosophy of ‘active support’. The approach taken promotes service users maintaining and developing skills, and accessing a range of opportunities. Input from staff is given in line with the needs and preferences of each individual. The service user group are able and independent in many areas, and this is encouraged and enhanced by the support they receive. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Service users’ strengths, needs, preferences and goals are reflected in their individual plans, which they contribute fully to devising. Service users are supported to exercise choice and control in all aspects of their daily lives. Service users are supported to take positive risks and access new opportunities, as part of an independent lifestyle. EVIDENCE: Sampled care plans were clear, comprehensive and up to date. Service users have significant input into the documents. Records are discussed with them, and they sign to indicate this. Some are also written in the first person, based on the person’s own words. This process is developing, in line with the application of ‘person centred planning’. A service user showed the inspector their own folder, filled with information about important aspects of their life, and illustrated with relevant photos. It was clear that the person was fully involved and engaged in producing this plan, which was proving a meaningful way of getting them to identify their own goals. Further staff training on the Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 11 new approach to care planning was scheduled to take place later in August 2005. Each service user has an allocated staff keyworker who works closely with them. They produce monthly keyworker reports on each person. These are summaries, compiled from other records, and talking to the individual. These monthly updates provide good evidence of regular review. Fuller reviews are also held at suitable intervals. Other relevant people contribute to these, such as relatives, and any professionals involved with an individual’s care. For service users at Sambourne Road, decision making is an integral part of their lives. The approach underpinning all that the home does is to promote opportunities to exercise independence. This is set out in a mission statement called ‘Our House, Our Choices’, which stresses each service users’ right to make choices in all aspects of their daily lives. This is within a framework of taking a full part in all the necessary jobs in the household, and attending any other settings that form part of the weekly routine. A sampled service user plan showed a good example of the person being enabled to make significant changes, in keeping with their own wishes. Due to anxieties associated with the weekly programme that they had been receiving, and the detrimental effects of this, the whole approach had been reviewed and discussed with the individual. Following this, it had been completely revamped, to bring it into line with their current preferences. If any limitations are put in place, the reasons for these are documented within individual care plans and risk assessments. Each service user also has a range of risk assessments. These too showed that they are regularly reviewed. Evaluations had also been carried out in response to any changes in circumstances, or significant events. The approach taken balances benefits and harms, and is being used positively to promote opportunities for service users. If controls have to be put in place, this is kept under review. Programmes are developed with the individual to build their skills, so that the controls can be relaxed when appropriate. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 & 17 Service users have opportunities for personal development. Service users have regular opportunities for appropriate activities, both at home and elsewhere. Service users are able to maintain and develop key relationships with family and friends. Service users are supported to plan and prepare appropriate meals. EVIDENCE: Service users are supported to develop their independence and to reach their maximum potential. The current group are able in many areas. Support from staff therefore often takes the form of advice and encouragement. People are enabled to have control in many aspects of their daily lives. For instance, using clear and detailed risk assessments to support individual judgements, service users are able to be in the house without staff supervision Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 13 for set periods of time. In connection with this, they have been able to demonstrate sets of key skills that uphold their safety. Service users regularly undertake naturally occurring tasks, such as answering the door to visitors, and making drinks for people. They are also allocated responsibility for the various household chores. Each person therefore contributes their fair share to the overall daily running of the home. People undertake a range of activities outside the home. These include some day service resources that are specifically for people with learning disability. Service users also attend sessions at local colleges, and some have either voluntary or paid employment. 2 people showed the inspector work they had produced at college, and also certificates relating to qualifications they had gained. Another returned from work later in the afternoon, and spoke about their job, and how much they enjoy it. The person is now able to receive a small amount of ‘therapeutic earnings’ each week, in recognition of the service they are performing in their local community. Service users can choose how to spend their leisure time at home. Each has their own bedroom. There is also a quiet room upstairs, which is used by people for hobbies such as sewing, and personal computing. People also regularly access amenities in the local community. They are enabled to do so independently, in line with risk assessments. Some can also travel further afield, making use of public transport. All service users had just returned from holidays. The female service users had been to Torquay. They showed the inspector their holiday photos, and spoke about what an enjoyable time they had had. The males had been to Blackpool. People are able to maintain key relationships. All service users have some family contact. They are supported to visit their relatives. People also have some other significant friendships, such as former residents, colleagues from work or college, and members of churches they attend. This means that some individuals have very active social lives. Information about important relationships forms a key part of person centred plans. One service user showed the inspector the various photographs of their family and friends, and explained the contacts that they have with each. Service users’ own rooms are considered their private personal space. People have keys to their bedrooms, and lockable space within them. Staff will not enter without permission. Agreements are in place about emergency situations that might mean having to override this. Service users have unrestricted access to all communal areas, and keys for the front door, in line with risk assessments. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 14 Service users have full involvement in the planning and preparation of meals. Each individual is given an amount of housekeeping money at the beginning of each week. They retain responsibility for this over that period, and return any receipts and change at the end. Service users then have an allocated day when they prepare the main meal. Menus are planned through discussion, and a knowledge of each other’s likes and dislikes. Alternatives are always available, if people prefer to opt out of the main option. Staff may give some input, to ensure that issues such as budgeting are considered fully. On the day of this inspection, the service user whose turn it was to cook the evening meal went shopping independently to buy the ingredients. They then prepared it, with occasional monitoring and advice from staff. It was clear that the individual enjoyed cooking, and was taking a lot of pleasure from the activity. They reported that they particularly liked foreign food, and the meal being prepared, of stir fried vegetables and pancake rolls, reflected this preference. Each service user is encouraged to buy fresh ingredients as much as possible, to avoid an over reliance on processed foods and ready meals. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 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 standard(s) 18, 19, 20 & 21 Service users are supported to address their personal and health care needs effectively. Service users control their own medication where possible, within appropriate procedures that ensure their protection. Issues of ageing, illness, death and bereavement are recognised, and service users are given support to deal with these sensitive topics. EVIDENCE: Service users at Sambourne Road require minimal assistance with personal care. Relevant information is included in their individual plans, and reflects each person’s own wishes in this area. Risk assessments also support judgements about safe levels of independence. Staff provide any support, reminders and encouragement, as required. Information about health needs is also clearly set out. Records are kept of any contacts that service users have with medical professionals. The home also monitors any key indicators that might be appropriate, such as weight. Service users who are taking any medication usually retain control of this. All those who were prescribed anything at the time of this inspection were being Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 16 supported to do so. Medication received into the home is recorded and stored centrally. Each person then receives a week’s supply, checked and dispensed into a dosette box. People are risk assessed for their capacity to be responsible for their own medication. Staff also monitor people, and give reminders if necessary. If any problems arise, situations are kept under review. For instance, one service user had been assessed as needing more staff support for a few months. They were given additional input to regain their skills and confidence, and were then able to take on greater independence once more. Some service users have experienced bereavement, such as the loss of a close family member. Records showed how the importance of this had been recognised, and how they had been supported through this difficult period. The service has a policy on the topic, and 2 staff were due to attend a relevant course in October 2005. The home also has a policy on supporting the changing needs of service users, for instance those associated with ageing and illness. This sets out how the ability of the service to continue offering a placement would be kept under review. The aim is to provide existing service users with a home for life, wherever possible. Where appropriate, service users have been enabled to address their own feelings about dying, and take practical measures, such as making a will. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 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 standard(s) 22 Appropriate procedures are in place for the protection of service users. EVIDENCE: Mencap’s organisational complaints arrangements are appropriate. Information on how to raise concerns is readily available for service users. This includes details on how to contact people outside the home, including the CSCI. There had been no formal complaints since the previous inspection. Some issues and disagreements can arise from time to time between service users. These are all recorded. Wherever possible, the aim is to resolve them in house, encouraging individuals to negotiate solutions to their own difficulties. But the other options are always made clear to people, and staff reported that service users are very aware of their rights, and capable of exercising these. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 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 Service users live in a homely and comfortable environment, in a location that enables them to fulfil their needs and lifestyles. Service users live in a clean and hygienic environment. EVIDENCE: 58 Sambourne Road is a spacious detached property, within a residential area of Warminster. It is conveniently situated for local amenities, and also for public transport links to other centres. Service users clearly benefit from being able to readily access a wide range of facilities independently. The property is owned and maintained by New Era Housing Association. It is decorated and furnished to a good standard, and provides a comfortable and homely feel. All service users have single bedrooms. One of these is on the ground floor. Each bedroom has a handbasin, but there are no other en-suite facilities. There is a shower downstairs, and a bathroom upstairs. An additional separate toilet is situated off the half landing from the staircase. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 19 The main communal space is a lounge with dining area on the ground floor. A spare room upstairs is designated as a ‘quiet room’, and is used by service users for hobbies and activities. Downstairs, there are also a kitchen, utility room, and the staff office, which is also used by the person sleeping in at night. The home has areas of garden at both front and rear. The front was overgrown and in need of some attention on the day of the inspection. The rear is paved, and provides a pleasant courtyard feel. None of the service user group smokes, and the home is designated as a nonsmoking area. The home was clean and hygienic in all areas seen during this unannounced visit. Service users participate fully in keeping it this way. Rotas allocate various cleaning tasks amongst the group. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 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 Staff cover is maintained at levels appropriate to meet the needs of service users. EVIDENCE: Staff to service user ratios are in keeping with the assessed ability levels of the group. There are usually 2 staff on duty during the daytime, with 1 person working in the evening, and sleeping in overnight. The home’s staff team consists of a manager, 3 full time support workers, and 1 part time. Mencap also has a pool of relief carers, who can be called upon to help maintain cover when necessary. This was happening at Sambourne Road during the week of this inspection, because of sickness absence. There were 2 staff on duty for the majority of the afternoon when this inspection took place. This enabled 1 person to support 2 service users on activities outside the home, whilst the other staff member remained to assist with the inspection process. There was 1 person on duty from 16.30 onwards, and they were being replaced at 18.00 by the relief worker, who was due to work the evening shift and the overnight sleep-in. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 21 Staff meetings are held once a month. Records of these showed that they are used to discuss a range of relevant topics. A communications book is also regularly used to pass messages between the team. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 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) 37, 41 & 42 The service has a qualified, competent and experienced registered manager in post. Improvements in record keeping would help to develop the effectiveness and confidentiality of service user records. The home has failed to notify all significant events to the CSCI, as required by care homes legislation. Suitable arrangements are in place to promote the health and safety of service users. EVIDENCE: The registered manager for 58 Sambourne Road is Mr Byron Nadgie. He has achieved the relevant qualifications now required of holders of this position. Over the previous year, Mr Nadgie has spent periods of time seconded to manage another Mencap service within Wiltshire. Other staff were seconded to Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 23 Sambourne Road to cover his absence. Mr Nadgie is now back at the service full time, although he was not present on the day of the inspection visit. Records showed effective communication between the manager and the staff team, and suggested evidence of good working relationships. Not all statutorily required records were checked during this inspection visit. Of those sampled, the majority were well maintained, clear and informative. However, some recommendations for improvements in service user recording were identified. Firstly, an entry in records relating to one service user referred to a health issue of a sensitive nature, but contained no details. From discussions with staff, it was clear that a fuller record had been made in a more confidential file. This appeared to have been an appropriate step, to respect the privacy and dignity of the service user concerned. But it would have been better for the more generally available record to be cross referenced to the confidential file. This would make clear that full information is in place, for those who might need to refer to it. Secondly, some detailed notes relating to service users were contained in general documents. Examples included the staff communications book, and the minutes of staff meetings. This meant that part of the care record for each individual was on the same document as information about other people. It was recommended that it would be better for these records to be kept separate. This would ensure confidentiality, and make an individual record easier to extract, if that were ever needed. The more general documents could contain a note directing people to the individual record. A recent incident had not generated a notification report to the CSCI, as should have happened. The event related to the unauthorised taking of a small amount of medication by a service user. Records indicated that the response to this had been appropriate, and suitable steps were being taken to prevent any recurrence. But the significance of the event was such that notification was required. Following discussion of this incident during the inspection, a report was to be provided by the home. Health and safety is given high priority, and various systems are in place to reflect this. There is a documented monthly workplace safety audit. Any issues highlighted are addressed as appropriate. Records show that any necessary services and repairs are carried out by relevant external contractors. There are also regular checks conducted and recorded in house by staff, on issues such as water temperatures. A range of general risk assessments support the health and safety practices in the home. Fire safety information was checked. The property was inspected by the fire safety officer earlier in 2005, and was judged to be complying fully with all necessary steps at that time. At this inspection, all required tests and staff Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 24 instruction were recorded as being carried out and up to date. Where any faults had been identified, it was clear that these had been reported and resolved. Fire drills and evacuation practices are carried out quite frequently, usually once a month. This is to ensure that all service users are fully aware of how they need to respond in an emergency situation, and supports risk judgements about their ability to be at home without staff supervision for some short periods. The property’s fire risk assessment was most recently reviewed in April 2005. This followed a full workplace risk assessment, which was carried out by Mencap’s health and safety advisor. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 3 x 3 Standard No 11 12 13 14 15 16 17 4 4 4 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sambourne Road (58) Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 x x x 2 3 x D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 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 YA41 Regulation 37(1)(e) Requirement The persons registered must notify the Commission without delay of any event which adversely affects the well-being or safety of any service user. Timescale for action From 17/08/05. 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 YA1 YA41 YA41 Good Practice Recommendations The Statement of Purpose and Service User Guide should be reviewed and completed. Service user records should contain clear cross-referencing to any relevant material that is stored more confidentially. Any information likely to form part of the overall record of care for an individual service user should be held separately from similar information about other individuals. Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 27 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sambourne Road (58) D51_D01_SAMBOURNE(58)_v193170_170805_Stage4.doc Version 1.40 Page 28 - 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. 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