Inspection on 22/08/07 for Saxby

This inspection was carried out on 22nd August 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Saxby 25/07/06

Saxby 19/12/05

Saxby 27/06/05

Saxby 11/01/05

Saxby 20/07/04

Saxby 14/01/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Saxby Upton Road Upton Aylesbury Bucks HP17 8UA Lead Inspector Jane Handscombe Unannounced Inspection 22nd August 2007 10:30 Saxby DS0000029711.V344545.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 Saxby DS0000029711.V344545.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. Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saxby Address Upton Road Upton Aylesbury Bucks HP17 8UA 01296 749969 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) Turnstone Support Limited Mrs Christine Barrett Care Home 4 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2006 Brief Description of the Service: Saxby is a small care home that is registered to provide care and accommodation to four service users with a learning and physical learning disability. The home is managed by Turnstone Support Housing Association. Saxby is situated in the village of Upton, which is a small village on the outskirts of Stone, but it is accessible to Aylesbury and Thame town centre and amenities. Access to amenities is via the homes own transport. The home is on a bus route to local villages and towns. Saxby is a single storey building, which has been refurbished and adapted to meet the needs of the service user group. All of the bedrooms are single. There is a car park at the front of the property and an enclosed rear garden. The current weekly fees are £1647.45 as indicated on the pre inspection questionnaire. Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This was a short notice announced inspection, which took place on 22nd August 2007, in order to see how the home is meeting the National Minimum Standards. Questionnaires were sent to all the service users, family members, and health care professionals in order to ascertain their views upon the care, support and services provided. Results of this inspection report are derived from responses to the surveys, case tracking, viewing policies and procedures, personnel files, along with any information that CSCI has received about the service in order to gain an understanding of how the services provided by the home meet the service users’ needs, and impact upon their lives. Comments received during the inspection process include: “The staff help me all the time, we all have different needs and get supported by the staff. I feel we are treated the same” (from a service user). “I like my support it’s a nice place. I’ve got a garden and a nice room…the staff are nice and friendly” (from a service user). “We have a sensory garden designed for me and housemates who have a sensory impairment” (from a service user). “Staff show an awareness of individuals’ privacy and speak to them in a respectful manner” (from a health professional). “Very dedicated to the care and welfare of the residents” (from a health professional). The service “looks at individuals needs and wishes first” (care manager). “As far as my client is concerned the staff at Saxby have always excelled in making sure his needs are not only met, but also strive to enable him to do individual activities outside the home and to participate in trying new experiences….” (care manager). “Treats X (named resident) with courtesy and respect at all times…encourages him to act independently as much as possible…” “The management and staff are most caring people, I could not wish for anything better…….it would be very difficult to improve their high standard” (from a relative). Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Whilst the service provides good outcomes for those using the service, a number of requirements and recommendations have been made within this report to address shortcomings found on the day of inspection, which are as follows: Undertake regular audits of care plans to ensure all assessments are signed by the person who undertook the assessment and the service user/representative to evidence they have taken part in the process. Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 7 Medication Administration Record sheets must be completed appropriately using the appropriate coding system to explain the reasoning for medication which has not been administered and it is recommended that Royal Pharmaceutical Society’s guidelines are followed in respect of administration of medicines away from the home. Appropriate documentation should be made in the home records detailing any medicines a service user has taken out of the home. It is reccommended that family members, advocates, health and social care professionals who visit the home and other stake holders be included in the quality review of the service to gain a more ‘rounded picture’ of the service. Any verbal complaints/concerns should be logged in the complaints book with details of any actions taken and the resultant outcomes The inspector would like to thank all those who gave their time in responding to surveys and speaking to the inspector during the inspection process. 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. Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 Quality in this outcome area is excellent. Information about the service is provided to prospective service users, in suitable format and visits to the home are encouraged enabling them to make an informed choice when choosing a service to meet their needs. All prospective service users undergo an assessment of need and aspirations before moving into the home, to ensure their needs can be met appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All current and prospective clients are provided with comprehensive information about the home, in the form of a Service Users Guide and a Statement of Purpose. The Service Users Guide is available in both picture format and written, to allow them to make an informed choice about whether the home is able to meet their needs. It was noted that the office copy needs revising as it does not include the present senior care worker for which a requirement has been made to ensure the Service Users Guide is regularly reviewed and updated as necessary. The inspector was assured that the present service users all have updated copies to include the member of staff and one user showed the inspector his copy, which evidenced that this was up to date. Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 10 Prior to moving into the home, all prospective service users undergo a thorough assessment of needs and a number of visits to the home are arranged, to ensure both parties are confident that the assessed needs can be met. Since the last inspection undertaken in July 2006, there has been one new service user admitted to Saxby. The service user was provided with an assessment via social services, after which the registered manager of Saxby met with the service user and the family to discuss the assessed needs and undertake their own detailed assessment. A further visit to the service user was made and arrangements were made to ensure that any needed equipment would be in place prior to the service user moving to Saxby. Meetings with the service user’s care manager and with the provider who was currently providing the care also took place ensuring that all aspects of care were taken into account. A number of visits to the home were arranged ranging from a morning to a long weekend to enable the prospective service user to meet with fellow users of the service, to meet with staff and to gain a ‘feel’ of the home before making a decision on where to live. Saxby take into account the current service users views with regard to prospective service users throughout the process to ensure a smooth transition for all parties concerned. From the evidence seen by the inspector and comments received, the inspector considers that this service is able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Saxby DS0000029711.V344545.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. Residents are involved in making day-to-day decisions about their lives, with staff support, are supported to take risks within a risk assessment framework which ensure that residents’ opportunities for involvement are maximised. Residents’ needs are reflected in their care plans. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Whilst visiting users of the service, the inspector found they each had an individualised plan of care detailing their health, social and personal care needs. Each was drawn up from an assessment of needs in which the service user, and/or family members and other health and social care professionals had taken part. Regular reviews of care are undertaken and care plans updated where change in needs has been highlighted. Evidence shows the service has been working to ensure user involvement is evidenced, although care needs to be taken to ensure all assessments are signed appropriately and Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 12 user representatives/independent advocate sign where the service user is unable to do so. A requirement has been made to address this. The care plans set out the action, care and support needed, taking into account the service users’ preferences and expectations, detailing how the staff are to meet their assessed needs appropriately. Where any risks had been identified, a risk assessment was in place detailing the risks and how these may be minimised whilst promoting users choices and independence. The care plans were developed in a suitable format according to each individual’s circumstances, and were found to be very person centred. Service users are encouraged and supported to make decisions about their lives. All of the users of the service reported to the inspector that they always make decisions about what they do each day, they can choose what they do during the day and at weekends. Regular residents meetings are held to gain service users views on different aspects of their lives, both within and outside of the home, all of which are minuted. A local independent advocacy service has been accessed to provide a service to those using the service and it is anticipated the advocate will work both in group discussions and when required on a one to one basis. The inspector discussed the protection of service users monies held within the home and viewed the financial documentation of one service user during the inspection. The documentation was in good order and provided a clear audit trail. Saxby DS0000029711.V344545.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. Service users live a full and varied lifestyle according to their wishes and preferences and are encouraged to maintain contact with their families, friends, representatives and the local community as they wish with support being given as required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users at Saxby enjoy various activities within the local community. Between the service users there are a variety of interests and hobbies which the staff encourage and support. Users of the service live full and varied lifestyles according to their wishes and preferences. Details within the care plans, daily notes and feedback from service users evidenced that all are actively involved within the local community and attend day service placements within the local area. Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 14 On the day of the inspection two users of the service enjoyed a shopping trip that morning with one of the carers. Arrangements for service users to meet with friends and family members are flexible and support is given to maintain personal relationships where required. Service users are actively involved in the planning and choice of daily menus and can take their meals with fellow users of the service around the communal dining table or privately if preferred. One resident informed the inspector of the innovative way in which staff gain the residents views and choices around food and menus….. “I am helped by staff to prepare food. We have a tape recorded menu; it is a book with photos – you press a button and it tells you what the food/menu is so that we can all choose”. Saxby DS0000029711.V344545.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. The home offers a high standard of care, which is well managed and planned around service users needs and preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service user has an individualised plan of care detailing their individual needs, preferences and goals and how these needs are to be met. Service users records viewed during the inspection indicated evidence that their views, preferences and needs are taken into account when providing care and support. Service users have the necessary disability equipment they require to enable them to maintain their independence and robust risk assessments are in place detailing how the care is to be delivered in a safe manner whilst maintaining and promoting the users independence. Of those service users being case tracked during the inspection it was evident that the carers spoken to were aware of their individual needs and had a good understanding of how to address their needs whilst promoting their independence. Feedback from a health professional states “excellent service Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 16 for my client even though he has different needs to what staff were used to. My client has gained in confidence, will now state his own views and is a much happier person since moving in”. Healthcare records were in good order and included separate records of contact with various healthcare professionals. The records indicated appropriate regularity of appointments and appropriate one-off consultations where necessary. Three healthcare professionals’ feedback was very positive on the service provided at Saxby. One states that the service is “very dedicated to the care and welfare of the residents” whilst another stated “the staff team are very motivated, they are interested in suggestions/ideas made by us. Staff will implement the suggestions and let us know if things are or are not working” a further states “excellent service for my client even though he has different needs to what staff were used to. My client has gained in confidence, will now state his own views and is a much happier person since moving in”. Staff are provided with training in safe medication practice and the policies and procedures for dealing with medication serve to protect the service users health, safety and welfare, although care must be taken to ensure the procedures are adhered to at all times. Whilst case tracking three service users provision of care and support the inspector viewed their Medication Administration Record (MAR) sheets, it was found that they were generally appropriately completed, including records of the quantities of medication received, although there were instances in which there were gaps, indicating that the medication had not been administered but no codes were used to indicate the reasoning, for which a requirement has been made within this report to ensure the medication administration records are completed appropriately. A further recommendation is made with regard to any administration of medicines away from the care home e.g. when going on leave; it is recommended that the home follow the Royal Pharmaceutical Society’s guidelines and appropriate entries are made in the home records detailing the medicines the service user has taken out of the home. Service users have been actively involved in choosing suitable lockable facilities in which they can store their medications in their own rooms, meanwhile the medication is stored appropriately in a safe manner in the office. Saxby DS0000029711.V344545.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. The home has policies and procedures to ensure users of their service and the staff delivering the care and support, are protected and safeguarded from any harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users and their family members/representatives are confident that any concerns or complaints they may have would be listened to, taken seriously and acted upon appropriately and if the need arose would use the complaints procedure. The complaints procedure is provided to all service users and explained to them regularly to ensure they have the confidence and understanding in using the procedure should the need arise. The home keeps a complaints log to record any complaints received in which they record details of the actions taken in response to any complaints. A recommendation was made to log any verbal concerns as well as formal written complaints. No complaints have been received by the home since the last inspection. All staff are provided with training around the safeguarding of vulnerable adults both in their induction training and regularly thereafter, enabling them to recognise the signs of abuse and how to respond if an allegation or incident is brought to their attention. Staff are all provided with and understand their responsibility to use the home’s whistleblowing policy if the need should arise. Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 18 The Commission for Social Care Inspection has not received any correspondence from the general public in relation to concerns, complaints or allegations since the last inspection Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30 Quality in this outcome area is good. Service users are provided with a homely, comfortable safe environment with appropriate disability equipment which suits their needs and lifestyles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides a clean, homely environment that is appropriate to the specific needs of the service users who live there. It is well-maintained and provides specialist aids and equipment to meet the needs of those who live there. All those using the service informed the inspector that the home is always fresh and clean. All service users have their own bedrooms and share a lounge/dining room, kitchen, bathroom shower room, laundry room and gardens which are safe, comfortable and adapted to the needs of anyone with a physical disability. The bedrooms are decorated and furnished to service users own personal tastes containing their own possessions. Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 20 Service users have access to safe, well maintained gardens and outdoor tables and chairs. Within the garden is a greenhouse and a vegetable plot. One service user explained how he enjoys gardening and growing vegetables with support from staff and family members. The registered manager discussed the problems highlighted during the last inspection, around ongoing issues with the lack of supply of water at the home at intervals during each day and confirmed that this has now been rectified. Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. All staff are trained and supervised to ensure they have the knowledge and skills to provide care and support safely and competently. Robust recruitment policies and procedures are adhered to ensuring the health, safety and well being of those using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s policies and procedures around the recruitment and selection of staff are robust and serve to protect service users health and welfare. Face to face interviews are undertaken, references sought and all the necessary checks are undertaken to ensure prospective staff’s suitability to work with vulnerable adults within the care field. Users of the service are involved in the recruitment and selection process to ensure their opinions are taken into account when selecting any new staff. All new staff, including sessional and agency staff, are provided with an induction period and undergo all the necessary training to ensure they have the skills and knowledge to undertake their roles competently. Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 22 Observations of the interactions between staff and residents indicated that staff clearly understood the individual needs of those using the service and showed skill in communicating with them effectively. Staff were seen to spend one-to-one time with individuals as well as interacting with them in a group. Staff training is recorded in individual staff files and those viewed demonstrated the home’s commitment to staff development and training. Staff members are encouraged to undertake the National Vocational Qualification (NVQ) in care. Three of the home’s eight permanent care staff have already obtained an NVQ level 2 or above and a further one is currently undertaking such training. Recent training has included fire awareness training, positive communication, mental health awareness training, adult protection and autism. Regular staff meetings are held within the home all of which are minuted and copies were seen within the home by the inspector on the day of the inspection. Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. Users of the service receive a well managed consistent service which takes into account their rights and best interests at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has, since the last inspection, undergone registration with the commission. She has the Registered Managers Award at NVQ Level 4 and is presently undertaking a degree in Health and Social Care. Since registration with the commission she has undertaken training in fire safety, protection of vulnerable adults update, manual handling assessor training and disciplinary process investigation skills. Service users and staff spoke in complimentary terms about her management ability and the support she gives as did the feedback from surveys sent out Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 24 prior to the inspection which included the following comments “she’s very approachable, friendly and easy to work with” and “she’s taught me so much”. The manager obtains feedback from residents and visitors when talking to them in the home, and has an ‘open door’ policy that encourages people to see her without the need to make an appointment. Regular monthly house meetings are held to gain the views of those using the service and through the use of service user questionaires which service users are asked/suported to complete given a variety of topics. Summary reports and Action plans are produced from these and reviwed quarterly . A reccommendation has been made to include family members, advocates, health and social care professionals who visit the home and other stake holders in the quality review of the service to gain a more ‘rounded picture’ of the service, collate the findings and feedback to those taking part. There have been regular monitoring visits undertaken by the provider with reports of these visits held within the home, all of which were made available to the inspector during the inspection. The home has a health and safety policy statement and provides training and equipment for staff. Safety checks relating to fire safety and infectious diseases are regularly carried out. Saxby DS0000029711.V344545.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 4 3 x 4 4 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 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 x x 3 x Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 14(a) (c) Requirement Timescale for action 30/09/07 2 YA20 13(2) Undertake regular audits of care plans to ensure that all assessments are signed by the person who undertook the assessment and the service user/representative to evidence they have taken part in the process. Medication Administration Record 30/09/07 sheets must be completed appropriately using the appropriate coding system to explain the reasoning for medication which has not been administered. 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 YA20 Good Practice Recommendations It is recommended that Royal Pharmaceutical Society’s guidelines are followed in respect of administration of medicines away from the home. Appropriate DS0000029711.V344545.R01.S.doc Version 5.2 Page 27 Saxby 2 YA39 3 YA22 documentation should be made in the home records detailing any medicines a service user has taken out of the home. It is reccommended that family members, advocates, health and social care professionals who visit the home and other stake holders be included in the quality review of the service to gain a more ‘rounded picture’ of the service and the findings be collated and fed back to those taking part. It is reccommended that any verbal complaints/concerns be logged in the complaints book with details of any actions taken and the resultant outcomes. Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Saxby DS0000029711.V344545.R01.S.doc Version 5.2 Page 29 - 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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