Inspection on 10/07/07 for Sandsground

This inspection was carried out on 10th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sandsground 17/07/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Sandsground Swindon Road Highworth Swindon Wilts SN6 7SJ Lead Inspector Pauline Lintern Unannounced Inspection 10th July 2007 9:45 DS0000064694.V341805.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 DS0000064694.V341805.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. DS0000064694.V341805.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandsground Address Swindon Road Highworth Swindon Wilts SN6 7SJ 01793 764948 01793 765181 janet.pagington@choiceltd.co.uk 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) Choice Limited Ms Janet Rosemary Paginton Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000064694.V341805.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th July 2006 Brief Description of the Service: Sandsground is a large renovated three-bedroom bungalow on the edge of Highworth. The home is on one level allowing service users access to all areas. In addition day care facilities are held in a large outbuilding in the garden. Communal living space includes a large living room and separate dining room.) There is a small quiet room at the front of the property and a small dining area adjacent to the kitchen. To the rear of the property there is a large enclosed garden and to the front a large stoned driveway and parking area sufficient for the needs of the home. The home is providing care and accommodation to three adults with challenging and complex needs and associated behavioural problems. The home will be staffed by a minimum of three staff on duty on all shifts. There is two waking night staff. DS0000064694.V341805.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection took place over six hours. The manager and area manager were present and assisted the inspector throughout the day. On arrival at the home there were no service users at home they were at day services. However, they returned to the home later in the day. The inspector was unable to communicate effectively with the service users to obtain their views. One member of staff met in private with the inspector. Prior to the inspection we sent out survey forms to relatives and staff to obtain their comments on the service provision at Sandsground. Three relatives replied and four staff. The judgements contained in this report have been made from evidence gathered during the inspection, which included examination of two care plans, risk assessments, complaints records, health and safety records, staff recruitment files, a tour of the premises and staff training. Medication procedures were inspected during a random inspection carried out by our pharmacist inspector on June 28th 2007. Medication practices were confirmed as good. Fees charged at Sandsground range from £2,207 per week to £3,872 per week. What the service does well: What has improved since the last inspection? DS0000064694.V341805.R01.S.doc Version 5.2 Page 6 All service users now have an assessment of their needs in their case file. They are also informed of the terms and conditions of their stay and the fees payable. Care plans are now kept under review and clearly specify how the needs of the person will be met. Care plans also contain information on any risks associated with their care. Each person has an activity record, which records how he or she found the experience. Any complaints made are kept in a log at the home and details the outcomes on separate pages. The manager has provided the staff with extra ‘in house’ training on the local procedure for making a ‘safeguarding adults’ referral. Eleven staff have received training in equal opportunities. Meals served are accurately recorded and any meals refused and alternatives given are also recorded. There is now a ramp for service users to be able to access the garden through the conservatory. There is now provision for air-cooling if required. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000064694.V341805.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000064694.V341805.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1 and 2 Quality in this outcome area is good. People are provided with information to enable them to decide if they wish to move into the home. Prior to moving into the home prospective users have their needs fully assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a statement of purpose available, which provides current information on the service that can be expected from the home. Each person is provided with a service user guide. Both documents are available in a version that has pictures, symbols and text. Each person has a copy of their contract with the funding authority and terms and conditions and fees payable. The contract is also in a pictorial version. Service user guides contain a pictorial copy of the home’s complaints procedure. Two case files were examined as part of the inspection process. Both files confirmed that a full assessment of needs had been completed to ensure that the home were able to meet them. There are guidelines to ensure that any transitions are smooth and encourage any families, friends, advocates or teachers where applicable to visit the home. During the assessment all areas of the individual’s needs are considered such as communication, mobility, emotional and physical needs, accommodation, social needs, health and dietary requirements. DS0000064694.V341805.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 6, 7 and 9 Quality in this outcome area is good. People who use this service have their assessed needs reflected in their individual care plan. Staff members empower service users to make decisions where possible, however the development of person centred planning could further promote their independence as adults. Risk management plans are reviewed by the psychologist however the home needs to ensure that assessments are reviewed at the time they are due so as to ensure any changes are taken into account and the safety of service users is maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two case files were sampled as part of the inspection process. Needs and personal goals are reflected in care plan along with risks and management plan. There is evidence to show that regular review meetings take place after six weeks, three months, six months and annually for the first year and then six monthly or as required. Case files detail the person’s communication needs within their communication DS0000064694.V341805.R01.S.doc Version 5.2 Page 10 support plan. One case file identifies one service user’s ‘objects of reference’, which are used as an aid to making choices. One staff member explained how one service user will make choices by pointing to things they want and by using their own signs for ‘yes’ and ‘no’. Particular attention was being given to the communication needs of service users. The manager explained that the home use a ‘tag system’ to ensure that communication is consistent between the staff members on duty and the service users who are at home. One staff member will be allocated a coloured ‘band’ at the beginning of their shift. This identifies them as the member of staff to ensure communication to one particular service user. This may be the staff member with the best relationship/knowledge or communication skills for the particular service user. It also ensures that one person takes responsibility for that person during the shift. During review meetings agreed action plans are developed, which outline the person’s goals and who will be responsible for actioning them. The manager reported that relatives of the service users are very involved in the management of their care provision. The manager confirmed that person centred planning could be developed further to ensure that service users are living the life,which they choose themselves. Each service user is allocated a key worker to provide consistancy and a sound knowledge of the individual by working on a one to one basis. Risk assessments are in place for each service user, however some were found to be just out of date and in need of reviewing. The manager confirmed that risk assessments are updated by the organisation’s psycologist and they are currently under review. All staff members sign to say that they have read and understood the risk assessments. The manager explained that the confidentiality policy has been explained to parents and service users. All staff members are trained and made aware of confidentiality regarding discussing individual’s care. DS0000064694.V341805.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12, 13, 15, 16 and 17 Quality in this outcome area is good. People using this service have access to day services and appropriate activities within the local community. There is a high level of family input. Menus are varied and mealtimes are flexible to suit the needs of the people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection it was recommended that the home develop weekly activity sheets to show whether the service user enjoyed the experience of any involvement in daytime or leisure activities. The activity sheets show that service users have accessed ‘music alive’ sessions, the homes’ snoozlem and participated in games such as ‘Jenga’. People have the opportunity to attend day services such as Upham Road and One Step Ahead where they can participate in aromatherapy, pottery, computer skills, jabadao, skittles and cookery. The manager reported that service users attend swimming twice a week and enjoy attending the London Road Disco. DS0000064694.V341805.R01.S.doc Version 5.2 Page 12 One service user’s case file states that they like trains, going to the pub, walking and going to the golf club where they can safely ride their bicycle. The manager has developed an information file on one of the day services for new staff members when they are on their induction. This contains information on the centre’s policies and procedures, person centred planning and codes of practice. One relative’s survey returned to us reported He seems very happy, his life has changed since he has been at the care home, he has a greatly improved interaction with outside activities”. There is evidence to show that service users have regular contact with parents and family members who visit the home or take individuals out, for days or overnight stays. The home ensures that service users birthdays are celebrated by having parties, which families are invited to. Service users can see visitors in their rooms if they wish and any additional seating will be provided. They can also see visitors in any of the communal areas of the home. The manager confirmed that keys are available to each service user but nobody uses them, they are hung outside each bedroom. Any mail received by the service user is given to the key worker who opens the letter in front of the person. Any celebration cards are opened by the individual themselves. The manager reported that they plan to encourage service users to become more involved with the selection of meals and participate in basic food preperation. She confirmed that at present they are involved in the house shopping in the local community. The home currently have a cook for five days of the week. There is a copy of the weeks menu on the wall in the kitchen. Plenty of fresh fruit is available for service users. Any refusal of food and any alternative given is recorded. One relative remarked that their relative’s “behaviour was getting worse due to too much processed food and this was affecting them especially at lunch time. This was changed with good effect. DS0000064694.V341805.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 18, 19 and 20 Quality in this outcome area is good. People who use this service receive personal care in a way that they prefer. Their physical and emotional needs are met with support from healthcare professionals and the care staff. Service users are protected by the home’s procedures for the safe handling of medicines. This judgement was made using available evidence including a visit to the service and discussions with the manager. EVIDENCE: Case files sampled showed that consideration has been given to ensure that service users are receiving their personal care in a way, which they prefer. There is a section ‘All about me’, which provides clear guidelines for personal care, the support needed and further actions that are required. Routines are clearly outlined for the morning, bathing, getting out of the bath, and attending day services and for the evening routines. All activities are supported by a summary of risk. One feature of this service is that the organisation has their own psychologist available to ensure that behavioural management guidelines are in place and kept under review. Service users consent to behavioural support, which is in a pictorial format. There is evidence of input from other health care professionals DS0000064694.V341805.R01.S.doc Version 5.2 Page 14 such as chiropody, doctors, speech therapist, community nurse and when needed a psychiatrist. Each person has a Health Action plan, which identifies his or her needs. The manager confirmed that service users are able to choose what time they go to bed and get up and are able to choose what to wear. As mentioned earlier in this report our pharmacy inspector carried out an unannounced inspection on 28th June 2007 following a concern reported to us. The inspector found this to be unsubstantiated following her inspection. Her findings were as follows: The home maintains clear records for medication and individual service user needs are taken into account when administering medicines. The home produces its own medication administration sheets, these should be signed and dated before use to show that they have been checked and are current. The same applies to the records for ‘as required’ medication. The manager confirmed that this recommendation has now been actioned. No service users are currently able to self medicate. Training from a local chemist has started for all carers who administer medication and the manager plans to introduce six monthly assessments to ensure that standards are maintained. A policy and procedure is available to all staff. Lists of staff signatures are in the front of the files. Medication administration records are produced by the home; these contain information to help staff administer medicines to the service users. They should be signed and checked before use. The records were checked and had been correctly completed. Changes in medication or dose were referenced back to records of doctors’ visits or letters from consultations or reviews. Weekly stock checks were done. Records of all drugs received into the home and returned for disposal were seen, along with records of medicines taken out of the home by service users on visits and returned if un-used. This ensured a complete audit trail of all medication. Medicines prescribed ‘as required’ were recorded on separate sheets with the dose, time of administration and reason for use. Any changes in the protocols for use of these medicines were evidenced through doctors’ letters and instructions. The pharmacy inspector made a judgement of ‘good’ for this standard. DS0000064694.V341805.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 22 and 23 Quality in this outcome area is good. The home strives to ensure the views of service users and their representatives are listened to. Staff members are receiving training in the safeguarding of adults and the procedures to follow if they suspect any form of abuse is taking place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy, which confirms that any investigations into written complaints are held within a 28 day period. The manager reports that all service users have been informed of the complaints procedure with the use of symbols and text, which has been explained to them by their key worker. There is evidence to show that any complaints made are investigated and dealt with immediately, with follow up actions as required. The manager explained that there is one on-going complaint, which is currently being investigated by the operations manager. However one person told the Commission of some concerns they had about the complaints system. One response received to the question: Has you complaint been responded to appropriately?, stated Up to a point but we are often given bland assurances that things are in hand or will be done and little happens. What we have been told is not always correct and we have been misled on many occassions. The manager confirmed that they have regular meetings and provide weekly feedback to parents. She added that they contact parents if there are any significant incidents or ooccurances when they happen. A recommendation made at the last inspection was for all staff to be made DS0000064694.V341805.R01.S.doc Version 5.2 Page 16 aware of the local procedure for safeguarding people. The manager reported that 75 of staff have received training on the Protection of Vulnerable Adults both by outside prioviders and internally. One member of staff confirmed that they would ‘feel confident to act on any concerns they may have’. They reported that they had not seen a copy of the Wiltshire and Swindon guidance ‘No Secrets’, however the manager confirmed that all staff have received a copy in her Annual Quality Assurance Audit, which was submitted to us. DS0000064694.V341805.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 24 and 30 Quality in this outcome area is good. People live in a homely, comfortable and safe environment at Sandsground. Infection control measures are in place and the home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector toured the premises as part of the inspection process and found it to be comfortable and well maintained. On arrival at the home cleaning was is progress and there were no unpleasant odours in the vicinity. All bedrooms were tidy and had been personalised with photographs, pictures and personal belongings. The manager confirmed that service users have unrestricted access to all areas of the house. The CCTV is not in operation at the present time due to one service user no longer having overnight stays at the home. The use of the CCTV is regularly reviewed at monthly contract operational meetings. A cooling system is now available for the hot weather if and as required. The manager confirmed that the sensory garden has now been finished and there is now a ramp to enable service users to access the garden safely. DS0000064694.V341805.R01.S.doc Version 5.2 Page 18 There is a sensory room, which is in a timber building outside of the home, which service users can access with staff support. This is fitted with lights, music system and tactile objects. There were plans to have adaptations made to the main bathroom, however the manager explained that they have been put on hold due to one service user not wishing to access the provision full time. It was noted that there was ample gloves and aprons for staff to use and antibacterial hand wash was available throughout the home. The laundry is situated away from food preparation areas and houses a commercial washer and dryer. Red alginate bags are used for the transporting of soiled laundry to the washer. Each service user also has an individual laundry bag. The manager reported that one service user would help staff to put their washing into the machine. Staff are provided with health and safety training, which incorporates infection control and control of toxic materials. The cook commented that some materials are locked away in the kitchen however the majority of toxic materials are locked in the garden shed for safety. DS0000064694.V341805.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 32, 34, 35 and 36 Quality in this outcome area is adequate. The home is ensuring that staff members are adequately trained and competent to carry out their duties. Feedback from staff surveys suggests that staff morale is low and that the team feel there is a divide in the staff group. There is evidence that staff are recruited following the correct procedures however some unexplained gaps in employment history could potentially place service users at risk. The frequency of formal supervision remains a concern. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current staff team appears to be a good mix of age, experience and gender and represents the racial mix of the local community. Feedback from staff surveys suggests that morale is currently low within the staff team. The manager confirmed that there have been some difficulties; the area manager further endorsed this. The manager commented that they hold regular team meetings, the last one being on the 1/5/07 to enable staff to share their views. Comments received from relatives include; “The care staff seem very caring people” and “ our relative has very complex problems and the high staff turnover causes difficulties”. The home currently has 2 staff vacancies and a manager’s post. DS0000064694.V341805.R01.S.doc Version 5.2 Page 20 Four staff recruitment records were examined and found that overall recruitment practices are good. However two records showed gaps in the employment history, which were unexplained. A requirement has been made to ensure that all gaps are explored to safeguard the service users. Checks are made on all new staff with the Criminal Records Bureau (CRB) before they commence employment. Two references are sought and proof of identity is obtained. Health questionnaires are also completed. Staff confirmed that they received a full induction, which covered policies and procedure and received an employee’s handbook. There is an induction information file for staff to use as a reference. The home has now adopted the Skills for Care Common Induction Standards. To further improve the safety of service users it would be good practice to provide staff with manual handling refresher training annually. Records demonstrate that training is provided in areas such as the safe handling of medication, Protection of Vulnerable Adults (POVA), health and safety, nutrition, pressure damage, epilepsy, basic food hygiene, fire awareness, first aid, manual handling and anti discrimination practice. The manager confirmed that following a requirement set at the last inspection eleven out of fourteen staff have now attended equal opportunity training. The lack of regular supervision remains a concern. One staff member reported that they had only received one supervision since March 06 and another stated that they do not receive regular one to one supervision. Records demonstrated that staff supervision is not happening as frequently as it should. The manager stated that due to staff shortages it was not always easy to arrange. DS0000064694.V341805.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home is managed by a competent and qualified manager who seeks the views of service users, parents, care managers and staff as part of a quality review. The health and safety of staff and service users is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A competent and qualified manager runs the home. It appears as mentioned earlier in this report that some staff members do not fully understand the role of the manager and this has lead to some difficulties in the past. This was discussed with the area manager and the manager during feedback. The manager confirmed that she will be leaving her post shortly and is moving to another provider to aid her personal development. The area manager confirmed that they are hoping to fill the managers position in the near future. The home has mechanisms in place to enable them to obtain the views of service users, staff, and relatives and care managers. Questionnaires were DS0000064694.V341805.R01.S.doc Version 5.2 Page 22 sent out in January 2007, the results go directly to the C.H.O.I.C.E. head office and the comments are then fed back to the manager. The results of the questionnaires formulate the next years development plan. The home ensures that regular health and safety checks are carried out within the home. There was a health and safety insurance audit completed on 6/10/06. The manager reported that she had identified two health and safety issues herself during the audit, which were added to the report. Records demonstrate that there are regular checks on fire fighting equipment, fire alarms and the emergency lighting system. Fire drills take place and there is a copy of the fire drill in a very clear pictorial format for staff to go through with service users. Staff members receive fire training, eleven staff attended on 5/7/07. It would be good practice to include the home’s policy on the evacuation of service users in the event of a fire and a service user refusing to leave the building in the statement of purpose. There is a current gas safety certificate dated 15/1/07 and evidence that electrical appliances were tested on 12/10/06. The home is recording accidents and incidents appropriately, however they are not using the recommended new version of the accident book. The manger confirmed that she would obtain the newer ones. All radiators are guarded and temperatures of hot water are recorded. Fridge and freezer temperatures are recorded and hot food is regularly probed to ensure safety. DS0000064694.V341805.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 1 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 DS0000064694.V341805.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 YA34 Regulation 19 Schedule 2 (6) Requirement Timescale for action 10/09/07 2 YA36 18(2) The registered person must ensure that staff members provide a full employment history, together with a satisfactory written explanation of any gaps in employment, if not already obtained. The registered person must 10/09/07 ensure staff receive formal supervision from a competent and trained person. This was a requirement set at the last inspection with a timescale of 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA42 Good Practice Recommendations It is recommended that the home further develop person centred plans to ensure that service users are living the life they choose. It is recommended that the home replace their accident DS0000064694.V341805.R01.S.doc Version 5.2 Page 25 3. 4. YA42 YA35 with the new recommended versions. It is recommended that the home’s policy on evacuation in the event of a service user refusing to leave the building is included in the statement of purpose. To further improve the safety of service users it would be good practice to provide staff with annual manual handling refresher training. DS0000064694.V341805.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000064694.V341805.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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