Inspection on 29/09/06 for Selborne House

This inspection was carried out on 29th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Selborne House 05/09/07

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Selborne House 34 Selborne Road Handsworth Wood Birmingham West Midlands B20 2DW Lead Inspector Alison Stone Key Unannounced Inspection 29th September 2006 10:30 Selborne House DS0000065913.V310184.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 Selborne House DS0000065913.V310184.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. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Selborne House Address 34 Selborne Road Handsworth Wood Birmingham West Midlands B20 2DW 0121 515 3990 F/P 0121 515 3990 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) Selborne Care Limited Mrs Lynn Lacey Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate 7 service users under 65 with a learning disability. Registration Category 7 LD New service Date of last inspection Brief Description of the Service: Selbourne house was formally a nursing home recently converted, designed specifically to provide a choice of accommodation to residents, offering rooms with en-suite facilities with some bedrooms also offering kitchenette and dining room facilities. The accommodation comprises 15 bedrooms in total divided into a 7 and 8 bed unit. There are several communal areas that can be used as residents and/or staff areas for the purposes of private meetings and or staff training and interviews. The care home is split into two areas called Ascot and Beverly; each unit has two lounges, a dining area and a separate office and medication room. The accommodation has a large patio area and a substantial garden. The home is located in the residential area of Handsworth Wood, and is close to main transport links. Shopping and leisure facilities are available in Handsworth Wood and Birmingham would be accessible. Selborne House is registered to provide nursing care, and the provider has recruited qualified learning disability nurses to lead each shift. The pre-inspection questionnaire completed by the manager states that fees cost up to £1500.00 per week. This information was given on the 13 September 2006. Readers of this report may find it helpful if they have any queries about fees to contact the Office of Fair Trading WWW.oft.gov.uk. The manager said that up to date inspection reports will be available in the agency’s office and/or copies can be provided on request. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork taking place a range of information was gathered and assessed. A completed pre-inspection questionnaire was received and information relating to the registration of the service was reviewed. One inspector carried out the unannounced fieldwork visit over six hours. This was the home’s key inspection. The staff on duty were spoken to as well as the operations manger who was available throughout the inspection. The inspector spoke with one of the three service users who lives there and three of the staff. A tour of the premises took place. Records relating to care, staff, health and safety and some policies and procedures were reviewed. The inspector would like to extend her thanks to every one who supported and contributed towards the inspection. What the service does well: Service users often go out to places they want to go to and they are supported by staff where needed to do this. Staff support and encourage service users to be as independent as possible in their own homes, encouraging and supporting them to do the cleaning, cooking and their washing. The organisation employs a part-time domestic assistant to keep the shared areas of the care home clean and tidy, this means care staff time is spent supporting service users. Service users said they could keep in contact with their family and friends, when needed staff support them to maintain these relationships. The family of one service user said that they were very happy with the support offered to their relative and the staff and manager were helpful and supportive. One service user said that they like living here because “staff help me to do the things I like to do and the staff are kind to me’. Staff training is comprehensive and staff are supported with all the necessary training to enable them to meet the needs of the service users. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Selborne House DS0000065913.V310184.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 Selborne House DS0000065913.V310184.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Prospective service users have the information they need to make an informed choice about whether or not they want to live at the home. Prospective service users individual aspirations and needs must be fully assessed. Each service user has an individual contract, so they are aware of the conditions that they live under at the home. EVIDENCE: Review of the Statement of Purpose and Service Users Guide included all the relevant and required information. The Service Users Guide was produced in a format that was easier to understand making it accessible to the service users who currently live in the home. Six service users have been admitted to the home since the home first registered as a new service, three have moved on and there were three people living at the home at the time of the inspection. One service user’s records were reviewed as part of the inspection. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 9 An assessment had been carried out by the social worker and the manager of the home, to ensure the staff would be able to meet the needs of the service user prior to the person moving in. Review of the homes assessments indicated this was a large detailed document offering a full assessment of each aspect of service users life, however it was noted that two sections of the service user’s assessment reviewed had not been filled out. Both of the assessments were noted to be signed by the service user, which means demonstrating their involvement in their assessment. The two assessments were further supported by the involvement of the service user in their own person centred plan. The home has an admissions procedure that includes all the relevant information including assessment of the individual and visits prior to moving in. The service user spoken to and his family supported the fact that introductory visits were arranged and they said that they felt supported by the staff and manager during this period of transition. The review of the service users file demonstrated that there was a contract in place with the home detailing the terms and conditions of living at the home, this had been signed by the service user, demonstrating their consent to living at the home under the terms and conditions detailed in the contract. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 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 the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Generally staff have the information they need to support individual service users needs and to support service users to achieve their goals. Service users are supported to make decisions about their lives and are involved in the running of the home. Service users are supported to take risks within an assessment framework. EVIDENCE: One service user’s records were sampled. Records indicated that care plans detailing the support the person needed, were regularly reviewed and the service user was involved in the review. The care plans detailed the service user needs, how staff were to support the service user needs whilst promoting their independence. Care plans were supported by individual Person Centred Plans and it was noted the care plans were cross-referenced to relevant risk assessments to support staff to enable the service users appropriately. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 11 The care plans were noted to include good information about the service user, including communication, daily routines, occupational support and the things the service user liked to do. Records showed that regular review meetings were held each month that involved the service user and people who were important to them. This process then informed the care plans and it was noted where the service users needs had changed care plans were updated accordingly. However care plans are based on the service user assessment and it was noted that one service user assessment had not been fully completed, this could lead to service users needs not being fully identified and planned for. Care plans and reviews demonstrated service user involvement. It was noted that there are not currently formal service users meetings in place or key worker meetings. However the service user spoken said that they met with their key worker weekly to discuss their care and support and discuss choices about what activities they wanted to do that week and what meals they wanted to eat. The service user spoken to said “staff always help me to do the things I like to do and support me to do things like cooking and cleaning, I like living here because I go out more and do things for myself”. It is required the process be formulated and recorded. It was noted that risk assessments are reviewed at least monthly and up dated where necessary. However a discussion with a member of staff demonstrated that the support given to a service user to make a cup of tea in their own room was different to the information detailed on the risk assessments in the service user file. The staff said that the staff team were aware of the service user current needs and associated risks and the key worker was in the process of updating new risk assessments. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 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 the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users experience a meaningful lifestyle that suits their needs and preferences. EVIDENCE: One service user spoken to said that they liked living here because staff had supported them to feel more confident about doing things for themselves, like going out independently. They said that they used to feel very nervous about going out but with the staff’s support feel much better about going out now and go out every day for a short walk to buy a newspaper. All three service users were out at the time of the inspection, two had gone out shopping and were staying out for lunch, another service user was at college. Three service user Weekly Activity Plan’s were reviewed these demonstrated service users took part in activities like listening to music, watching TV, Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 13 watching DVD’s, tidying their bedrooms, cooking meals, going to the pub for lunch and/or evening meals, going to the cinema, attending college, and visiting their friends and families. The service user spoken to said that they meet with their key worker every week to discuss what activities they wanted to do the following week. One service user said that staff support them to visit their family regularly and their friends and family can visit anytime. One relative said the staff supported them to have regular contact and always let them know about any issues and they were actively involved in review meetings. Key worker meetings are in the process of being set up and as yet service users meetings are to be arranged. The operations manager said that information relating to service users advocacy is available in the home and service users are encouraged to access an advocate if they feel that this will be helpful to them. It was noted this information was clearly displayed on the notice board. Each service user has a person centred plan and is involved in weekly meetings with their key worker to plan the week ahead, this included, new interests service users would like to take part in, planning house shopping, cooking meals and doing house work. Menus are based on healthy eating plans. Service user’s were involved in the design and choice of their meals and it was noted individual menus were in place. Staff spoken too said they encouraged service users to be as independent as possible with the preparation of meals, only offering support where necessary. One service users care plan had involved the dietician in supporting the service user with a healthy eating plan. Service users were able to eat their meals in a variety of places, including their own rooms with kitchenette facilities, the communal kitchen or the dining room. Kitchen cupboards were stocked with brand named food, offering service users a number of choices about what they wanted to eat. Mealtimes were flexible and designed around service users needs. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are supported or encouraged to undertake personal care in a way and time suited to them and their health needs are supported by staff. The management of medicine by qualified staff needs to improve to ensure practices relating to medication are robust. EVIDENCE: The care plan sampled detailed how staff are to support service users with their individual needs around personal care. The Person Centred Plan in place detailed great information about the person, like information about the people who are important to them, things they like to do, things they need help with and what that help involves. It recorded the things the service user enjoyed doing, like going on holiday, washing up, TenPin bowling, making craft things and doing art and shopping for CD’s. The plan talked about the person’s hopes and dreams for the future, including things like “I would like to eat healthily, keep myself fit and lose some weight”. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 15 The care plan and daily records indicated that staff were supporting the service users to achieve this goal. The Person Centred Plan also included a section on “Some things that are Important to ME”, this part of the plan said things like “When it’s my birthday, I like to celebrate my birthday with friends and family, I like buffets”, “it’s important to me to listen to my CD’s everyday”, review of the service user’s weekly activities indicated that this takes place. The service user record sampled showed that health professionals are involved in their care. These included Psychiatry, the community nurse, the GP and the dentist. Records sampled showed that the service user is supported to have regular health checks with the dentist, optician and chiropodist. Health Action Plans are yet to be developed. The development of individual Health Action Plans would support service users to have all their health needs identified, meaning service users could be supported to manage their health in a proactive way. Medication is stored in locked cabinets in a medication room in each of the two units. The local pharmacist supplies medication. Medication is administered to service users by a suitably qualified person. Medication Administration Records (MAR) had all been signed appropriately. The MAR cross-referenced with the tablets supplied by the pharmacist. Records indicated that all medication was checked in when it was received from the pharmacy and records clearly demonstrated when medication had been returned. Staff complete daily medication audits to ensure all service user medication has been given correctly. It was noted that on some of the service users prescribed creams, staff had not recorded this date when they first opened it. This practice could lead to topical creams being administered that are out of date. GP prescription charts were kept with service users MAR charts, this practice reduces the possibility of medication errors. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a robust complaints procedure so that service users views are listened to and acted on. Service users would benefit from this document being provided in an accessible format. Arrangements are in place so that service users are protected from abuse, neglect and self-harm. EVIDENCE: The complaints procedure is included in the Statement of Purpose and the Service Users Guide and each service user and/or their representative has a copy of this. It would be beneficial to service users who live at the home if this document was available in an accessible format. The pre-inspection questionnaire states that there has been one complaint made to the manager of the home since the service became operational in February 06. The review of this paperwork indicted this had been appropriately managed. The Commission for Social Care Inspection, the regulatory body who inspects services like this one, has not received any complaints about the service since it’s registration. All staff had received recent training in adult protection and the prevention of abuse. Some service users can display behaviour that can be challenging. Discussions with staff demonstrated staff had a good understanding of what to do in the event of a concern in relation to potential and/or actual abuse of a service user. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 17 The review of staff records indicated that all staff had received training in how to manage these types of behaviour positively and prevent service users selfharm. Service users records included an inventory of their belongings that was completed when they first moved into the home. Service users are their own appointees and they had lockable facilities in their bedrooms to enable them to keep their money and important personal items safe. Further lockable facilities were also available in the office. Staff support service users with the day to day management of their own finances, however details of service users needs in this area and the actions staff should take to support service user were not clearly recorded in individual care plans. This would ensure robust staff practices around the management of service users finances. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users live in a homely, comfortable, safe and clean environment that meets their individual needs. EVIDENCE: The home is well decorated and furnished. The home was originally a nursing home and the organisation has undertaken a large amount of building work to sympathetically convert the original building to a 15-bed care home, comprising of a 7 and 8 bed unit. Communal areas are spacious, and the home benefits from being completely refurbished and decorated to a good standard. The home was clean and tidy and free from offensive odours throughout. Service users are supported to do their own cleaning, the cleaning of the home is carried out by a part-time domestic assistant, the operational manager said there are plans to increase the domestic assistants hours to full time when the home is full. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 19 Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are enough staff to meet the needs of the service users accommodated. Service users are supported by staff who have received training so they can meet their individual needs. Service users are protected by the home’s recruitment policy and practices. EVIDENCE: The pre-inspection questionnaire stated 33 of care staff had NVQ level 2 in Care or above. This is below the standard of at least 50 of staff having completed this training. Selborne House is registered to provide nursing care. Currently there are at least three staff on duty at all times to support the three service users who live there, including a qualified nurse. Staffing levels will increase as more service users move in. Staff records indicate that staff were supported with good inductions and these were comprehensive, which covered good practice and service user’s specific support needs. The review of staff records indicated that all staff had completed an induction prior to working with service users. Staff are supported Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 21 with training in how to positively manage service users behaviour that challenges, this training is regularly updated. The staff are also given a copy of the General Social Care Council’s Code of Conduct and the organisations own staff handbook to further support them with their role. It was noted that five staff have recently attended an event in Manchester all about supporting people with Learning Disabilities, future training planned included the Learning Disabilities Award Framework, mentorship in practice to support the seven qualified nurses employed, training in Autism, the NVQ assessor’s awards and two staff are going to undertake their Registered Manager’s Award. Regular staff meetings are held and the majority of staff attended these, including the night staff. These are focussed on service users and how staff are supporting them to meet their needs and achieve their goals. Four staff recruitment records were sampled. These included proof of the person’s identity, a completed application form, two written references and evidence that they are physically/mentally fit to do the job they are employed to do. Evidence that Criminal Records Bureau (CRB) Disclosure’s and Protection Vulnerable Adults list checks had been undertaken, to ensure that staff employed are suitable to work with the service users. Staff records indicated staff were regularly supervised and this process was further supported by supervision contracts. Qualified staff were supported to update and maintain their nursing skills and knowledge through regular clinical governance meetings. Review of staff supervision records demonstrated staff were appraised and their performance was regularly monitored, any issues were discussed in supervision with the manager. Supervision records also indicated staff’s training needs were looked at as part of the supervision process this ensures staff are appropriately trained to meet the needs of service user’s and supported their own personal and professional development. The operations manager said that staff would be supported with annual appraisals, however this had not been completed yet as staff had not been in post a year. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, & 42 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a well run home. More work needs to be undertaken to demonstrate how service users views underpin all self-monitoring, review and development by the home. The health, safety and welfare of service users is promoted and protected. EVIDENCE: The manager of the home is an experienced qualified nurse in the field of learning disabilities, she is supported by a qualified team of seven nurse’s and care staff. The service user spoken to and their family said that the manager listens to them and supports them. The organisation currently doesn’t have a Quality Assurance Process; the operations manager said this is something they are in the process of developing for the organisation. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 23 This process will involve canvassing the views of key stakeholders including, service users, their relatives and/or their representatives, social workers and other involved professionals. Currently service users views are undertaken via key worker meetings, regulation 26 visits where the operations manager comes to the home and spends time talking to service users about their views on the home, these are fed back to the manager, a copy of this report is forwarded to CSCI. Regular service user reviews are held and these were noted to involve the service user and people who are important to them like their families. Fire records showed that the member of maintenance staff regularly tests the fire equipment to make sure it is working appropriately. Regular fire drills are held so that staff and service users know what to do in the event of a fire in the home. An engineer checked the fire alarm system on the 28 March 2006. Staff have received fire training 10 August 2006 and the organisation is aware of the new fire regulations and has put into place the appropriate risk assessments in line with the new rules around fire prevention. Risk assessments are in place for staff, the premises and food safety. The operations manager said these would be regularly reviewed at least annually. As part of the inspection the kitchen areas were looked at, it was noted that in one of the fridge and the freezer there were a number of food items that had not been labelled to inform people when they had been opened. The labelling of fresh and frozen food when it is first opened is important to ensure service users do not eat food that has gone past it best before date, as this could lead to potential incidents of food poisoning. A Corgi registered engineer tested the gas equipment on the 15 November 2005 to make sure it is safe to use. They stated that it was in a satisfactory condition. An engineer completed the five-yearly electrical wiring test 28 September 2004. It was noted that the water temperatures are checked weekly to make sure the water service users use is not too hot or too cold. A valid certificate of employers liability insurance was displayed. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 25 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 YA2 Regulation 14(1) Requirement The registered manager must ensure all service users needs are fully assessed. The registered manager must ensure care plans reflect all service users changing needs and personal goals. The registered manager must ensure that they can demonstrate how service users are supported to make decisions about their lives. The registered manager must ensure that there are appropriate risk assessments in place to support service users The registered manager must ensure it can be demonstrated how service users rights and responsibilities are reflected in their daily lives. The registered manger must ensure all staff practices in relation to medication are robust. DS0000065913.V310184.R01.S.doc Timescale for action 29/10/06 2. YA6 14 29/10/06 3. YA7 12(3) 29/12/06 4. YA9 13(4) 29/12/06 5. YA16 12(4)(a) 29/12/06 6. YA20 13(2) 29/11/06 Selborne House Version 5.2 Page 26 7. YA23 13(6) 7. YA37 8 The registered manager must ensure service user’s care plans detail how staff are to support service users with their finances. The registered manager must ensure all records relating to service users care are fully completed and care plans and risk assessments are comprehensive and accurate. 29/12/06 29/11/06 8. YA39 2491)(a)(b)(2)(3) The organisation needs to 28/02/07 develop a process to assess the quality of care provided to the service seers. 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 YA22 Good Practice Recommendations The registered manager should make arrangements to ensure the complaints policy is available in a format that the service users can access. Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Selborne House DS0000065913.V310184.R01.S.doc Version 5.2 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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