Inspection on 05/07/06 for Shaftesbury Court

This inspection was carried out on 5th July 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 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shaftesbury Court 26/10/07

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

CARE HOME ADULTS 18-65 Shaftesbury Court High Street Winslow Bucks MK18 3HA Lead Inspector Mrs Maureen Richards Unannounced Inspection 5th July 2006 09:30 Shaftesbury Court DS0000067532.V305481.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 Shaftesbury Court DS0000067532.V305481.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. Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shaftesbury Court Address High Street Winslow Bucks MK18 3HA 0845 337 0445 01905 338461 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) www.sanctuary-care.co.uk Sanctuary Care Ltd Mrs Lesley Isobel Smith Care Home 18 Category(ies) of Learning disability (18), Learning disability over registration, with number 65 years of age (1) of places Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Shaftesbury Court is located toward the end of the village of Winslow, close to shops, pubs, transport links and a medical centre. The home has recently been taken over by Sanctuary Housing and provides accommodation for up to seventeen adults with learning disabilities. The home is divided into small groups, each with its own lounge, kitchen/dining area, bathroom and toilet facilities. There is an additional central common room. The home has a garden and there are parking facilities at the front of the building. The current fees are £650 per week. Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over two days. The key National Minimum Standards for younger adults were inspected and the progress in meeting requirements from the previous inspection was evaluated. A requirement made at the previous inspection to provide challenging behaviour training for staff has not been complied with and this has been repeated at this inspection. Comment cards were received from service users, relatives and professionals involved with the home. Fourteen comment cards were received from service users who indicated that they were happy at the home. Nine comment cards were received from relatives who indicated that they were happy with the care given to their loved ones. One relative raised issues in relation to the cleaning of the home, which has been referred to under standard 30. Feedback was received from eight professionals involved with the home. Six of those professionals indicated that they were happy with the home and care given to their clients. Two professionals raised some issues, which have been referred to within the body of the report. The inspection involved discussion with the manager, discussions with five staff, a tour of the environment, examination of some of the required records, observing handover, a one to one discussion with two service users and informal discussions with other service users. The home was taken over from Ashley Homes by Sanctuary Housing and the registration with the Commission took effect from the 31st May 2006. What the service does well: Service users are supported with their individual programmes and to take part in meaningful activities. Family involvement is supported and encouraged. Service users are supported to be involved in aspects of their care and decision making at the home. Individuals are supported to develop their independence. Service users are provided with a choice of meals, which are varied and balanced. Service users personal and healthcare needs are met and monitored. Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 6 Medication is generally well managed. Recruitment of staff is well managed and staff files are well organised to support this. The home is well run, monitored and managed and staff confirmed that they are clear of their roles and feel happy and supported in their roles. Excellent health and safety records are in place, which indicate that health and safety issues are attended to. What has improved since the last inspection? What they could do better: The assessment documentation should be developed and records of meetings and discussions with other professionals concerning a prospective new admission should be included with the assessment documentation. Service user plans must be further developed to contain more specific guidelines for staff on how service users medical conditions, behaviours and situations are to be managed. Service users plans including risk assessments should indicate service users involvement and be kept updated and reviewed. Clear guidelines and a protocol must be put in place on the administration of invasive prescribed medication. Specialist training and mandatory training must be made available to staff within the required timescale to ensure the safety of service users and staff. Sanctuary Housing policies and procedures should be made available to the home and understood by staff to ensure that staff are following the correct procedures as required by Sanctuary Housing. A programme of redecoration and renewal should be made available to the home to ensure that all areas of the home are kept maintained and updated. Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 7 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. Shaftesbury Court DS0000067532.V305481.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 Shaftesbury Court DS0000067532.V305481.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The assessment documentation needs to be developed to ensure that service users are fully assessed prior to admission to ensure that the home can meet their needs. EVIDENCE: The home has had two admissions since the previous inspection. The assessment documentation on one file related to a previous admission in 2003. The manager confirmed that this individual was reassessed prior to this admission due to a change in this individuals needs. The documentation was eventually located but the assessment documentation for both new admissions was not dated and signed by the manager. The manager confirmed that there had been lots of discussion and involvement with other professionals prior to admission of service users but this information was not held with the assessment documentation to support this. The manager confirmed that she and a team leader or senior is involved in assessments. Service users are consulted and made aware of prospective new admissions and the monthly service user meeting minutes seen support this. Shaftesbury Court DS0000067532.V305481.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 poor. This judgement has been made using available evidence including a visit to the service. Service users plans lack specific detail on the management of medical conditions, behaviours and situations and are not regularly reviewed. This potentially fails to provide continuity of care for service users and put staff and service users at risk. Service users are given the opportunity to make decisions, which promotes their involvement in aspects of their lives. Risk assessments are not kept updated and reviewed which potentially puts service users at risk. EVIDENCE: Five service user plans were viewed at this inspection. Service user plans contained personal detail information on individuals, a photograph, and an outline of routines in relation to personal care. Service user plans contained support plans in relation to support required with personal care, Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 11 communication and health needs. The service user plans seen lacked specific detail on how individuals’ medical needs, situations and behaviours were to be managed. Some service user plans did not pick up on specific issues for example anxiety and challenging behaviours as identified as part of the care managers review. Service user plans did not show any evidence of service users involvement in their development and some service user plans had not been reviewed since their development on admission in some cases, which was in 2002 and 2003. The manager confirmed that they are due to introduce person centred planning but the home does not have access to a coloured printer to facilitate this. Service users are supported to make decisions and choices in their everyday life. Some service users have advocacy involvement to facilitate this. Each group has a monthly meeting and decisions are made on trips, activities and other aspects of living together. Service user plans include risk assessments. Risk assessments are in place in relation to a particular activity for example a trip out. Some service users plans include risk assessments specific to individuals and moving and handling risk assessments where required. There were no risk assessments in relation to the management of specific behaviours and some risk assessments had not been updated or reviewed since the date of implementation in 2002 and 2003. This must be addressed. Shaftesbury Court DS0000067532.V305481.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 have access to a range of activities, which takes account of their individual interests and hobbies. Family support and involvement is supported which benefits the service user. Daily routines promote service user involvement and independence, which enables and encourages them to take responsibilities in their daily lives. Service users choose and are provided with a varied and balanced diet, which promotes their well bring. EVIDENCE: Service users have an individual programme of weekly activities, which include day service attendance, a structured home care day and leisure activities of Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 13 their choice. The service user meeting minutes indicate discussions on service users choice of leisure activities. The home does not have its own transport and can access community transport for specific activities and trips. The manager confirmed that they are currently reviewing the staffing structure to allow for more flexibility within staffing to further develop activities. Service users families and friends are made to feel welcome at the home. Comment cards received from relatives of service users support this and this was observed during the inspection. Service users are supported to develop their independence and choices. All of the service users have a home care day and have one to one input from a member of staff to support them with practical skills and household chores including shopping and cooking. Staff only enter service users bedrooms with their permission. Service users have a key to their bedroom and are encouraged to keep their door locked when out. Staff support service users with their post as required. Service users can choose when to be alone or to join an activity and have access to all areas of their individual groups. Service users have three meals a day with drinks and snacks being available as required. Meals are prepared and cooked in individual groups. The menu plan is agreed at the monthly service user meetings and service users can change their meal choice as and when they want. A comment card received in respect of this inspection indicated that staff changed the menu plan to cook what was easiest for them. The menu plan seen indicate some changes and it is advised that a note is made on the menu plan to indicate why the menu plan is changed. The menu plan record was amended to include a column for this by the end of the inspection. Service users commented that they were happy with the meals provided. Shaftesbury Court DS0000067532.V305481.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. Systems are in place to ensure that service users personal care and healthcare needs are met and monitored which promotes their well being. Medication is well managed which promotes service users well being. Clarification is required on the administration of invasive medications to further support good practice and to ensure the safety of service users. EVIDENCE: Service user plans make reference to the support required by individuals in meeting their personal care needs. Service users plans include moving and handling guidelines as required for individuals. Service users personal care needs are provided in private and some of the service users spoken with confirmed this. Service users are prompted to get up to attend to their daily programme and some service users confirmed that they choose when to go to bed. Service users have access to technical aids and equipment as required to promote maximum independence. Service users have access to a wide range of professionals and specialists. Records are maintained to confirm this. Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 15 General nursing care is accessed through the General Practitioner and specialist nursing input is provided by the Community Learning Disability team. Service users have a designated key worker and service users plans outline individuals routines, likes and dislikes. All of the service users are registered with local General Practitioners. Service users have access to a wide range of healthcare provisions including the dentist, opticians, podiatrist and specialist services. Records are maintained of the outcome of all healthcare appointments. One of the current service user group is self-medicating. The medication supply is stored on each group. Only the team leaders and the senior are responsible for the administration of medication. One of the team leaders is responsible for the ordering, receipt and overseeing of the medication. The medication administration records and the storage of medication on two groups were viewed at this inspection. The medication administration records indicate that all medication received into the home is signed for and there were no gaps in the current administration records. All over the counter medication is agreed with the General Practitioner and included on the medication administration sheet. The storage of medication is well organised with external medicines, for example shampoos and creams stored separately from tablets. The home keeps a stock check of all medication and a record of disposal of medication. The team leader confirmed that staff responsible for administering medication would be inducted into the procedure by experienced staff. She confirmed that she and other staff responsible for medication has attended medication training. The home has some service users who are prescribed rectal diazepam. There is no indication on the medication administration record as to who would administer this medication when required. Staff have not been assessed and deemed competent to administer this medication. Therefore the manager must contact the General Practitioner who prescribes this medication to agree a protocol for administration of this medication. If staff are required to administer this medication they must be trained and deemed competent by a suitably qualified Practitioner to do so. A written protocol must be put in place to outline the agreed procedure. A healthcare professional commented that if a medication error is made the policy should be followed through consistently. Senior and team leaders meeting minutes indicate that all staff responsible for administering medication are reminded of the procedure for reporting medication errors and memos are on file to all team leaders to support this. Shaftesbury Court DS0000067532.V305481.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 adequate. This judgement has been made using available evidence including a visit to the service. The home has an effective complaints procedure in place to enable service users to address issues. Sanctuary Housing adult protection polices must be made available to the home and support staff must receive adult protection training to ensure the protection of service users. EVIDENCE: The home has a complaints procedure in place including a pictorial complaints procedure. All issues raised are logged as a concern and responded to by the team leader on shift and followed up by the manager. Service users spoken with confirmed that they are aware of how to make a complaint and would talk to their key worker, team leader and or manager with any concerns. The home has information displayed on the notice boards for service users on how to recognise and respond to abuse. The manager has facilitated an in house training session to raise service users awareness of what is abuse as required at a previous inspection. The manager confirmed that she and two of the team leaders have attended the Buckinghamshire training on abuse and plan to deliver this training to other members of the team. The manager has devised a questionnaire to establish staffs understanding of abuse to know what level to pitch the training at. A requirement was made at a previous inspection that training on protection from abuse is to be undertaken by all Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 17 staff. The timescale for this requirement is the 1/10/06. However until adult protection training has been provided for all staff this standard will not be met. Staff spoken with were clear of their responsibilities to report abuse and bad practice. The home has Ashley Home policies in relation to the protection of vulnerable adults. They were not viewed at this inspection and must be replaced by Sanctuary Housing policies and procedures. A healthcare professional commented that the whistle blowing policy should be made known. The staff meeting minutes confirmed that this has been discussed and reinforced. Shaftesbury Court DS0000067532.V305481.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): Outcome in this area is adequate. This judgement has been made using available evidence including a visit to the service. The home is generally clean and homely. Areas of the home are in need of updating and a programme of redecoration and refurbishment should be made available to the home to provide a comfortable environment for service users. EVIDENCE: The home has a common room, which the front door opens straight into. A keypad has been fitted to this door to prevent people walking into the home without the knowledge of the staff. However on day one of the inspection the service users opened the door to the inspector and the inspector was allowed into the home without the knowledge of the staff who were located in other areas of the building. Service user meeting minutes indicate that this has been discussed with service users but it continues to be a security issue. The living areas are divided into four individual flats, which include individual bedrooms, a shared dining/kitchen area, sitting room and bathroom and or shower. The bedrooms seen were found to be personalised and homely. Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 19 Areas of the home are showing signs of wear and tear and are in need of redecorating and updating. One of the sitting rooms was sparsely furnished and some of the furniture in this room was mismatched and the settee was well worn. The manager was unable to advise when finances would be available to update this furniture. Some of the kitchen cupboards were falling off their hinges, the flooring in some of the bathrooms was badly stained and the bathrooms are in need of updating. The home does not have a programme of redecoration and renewal in place and this should be provided to ensure that all areas of the home are kept maintained and updated. The garden was well maintained and nicely presented. Staff are responsible for the cleaning of the home. The home was found to be clean and presentable. Service users are supported to clean and tidy their bedrooms on their homecare days and some service users get involved in doing other tasks around the home. One comment card from a relative commented “that they would like to see a cleaner in the home as this would give the carers more time for one to one quality time with service users and able to provide more activities”. Shaftesbury Court DS0000067532.V305481.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 Outcome in this area is adequate. This judgement has been made using available evidence including a visit to the service. The home has effective recruitment procedures in place to ensure the safety of service users. Staff do not have specialist training and some staff do not have the required mandatory training, which could affect the safety and well being of service users. EVIDENCE: Staff were observed to be accessible to, approachable by and comfortable with service users. Service users spoken to confirmed that staff were kind and caring towards them and they enjoyed living at Shaftesbury Court. The manager confirmed that staff are reliable, honest, motivated and committed and this is evident by the number of staff who have worked at the home for a considerable length of time. A comment card from a professional commented that some staff are not happy in their work and this affects the care some service users get. Five staff spoken with during the inspection confirmed that they are happy in their work and appeared positive about their role. The training records indicate that staff do not have access to specialist training to support them in their roles. A requirement was made at a previous Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 21 inspection that training on understanding and responding to challenging behaviour is to be made available to the staff team. The manager confirmed that she has attended this training but to date this is outstanding for staff and the requirement has not been complied with within the previous timescale. The home has developed professional relationships with other professionals and the majority of comment cards from professionals support this. A healthcare professional commented that communication within the home needs to be improved but there were no specific examples given as to what this related to. The pre inspection questionnaire did not indicate how many staff have a National Vocational Qualification and this was not established during the inspection. Four staff files were viewed at this inspection. The files seen included all of the schedule 2 information to confirm that all staff have the full range of required recruitment checks. There was evidence from agencies that the staff they supply also have all of the required checks. Staff files are well organised and the information easily accessible. Staff files include an individual record of training undertaking. The staff training records seen indicate that new staff do not have all of the required mandatory training within six months of commencing work at the home and new staff do not have food and hygiene and moving and handling training but is expected to be involved in those tasks. Other staff have been identified as requiring updates in mandatory training but the mandatory training is not planned until the latter part of the year when this training and updates will be overdue. This must be addressed to ensure that all staff have the required up to date mandatory training to ensure the safety and well being of staff and service users. Shaftesbury Court DS0000067532.V305481.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 Outcome in this area is good. This judgement has been made using available evidence including a visit to the service. The home is effectively run, managed and monitored to ensure that it meets service user needs and promotes their well being and safety. EVIDENCE: The manager has been a registered manager of the home for over three years. She has obtained her National Vocational Qualification level 4. The registered manager is clear of her role and responsibilities. Staff spoken with confirmed that they feel the home is well managed and the manager is supportive of them in their role. The organisation carry out monitoring visits of the service and reports are maintained of those visits. The manager confirmed that the organisation carry out an annual audit of the service which includes feedback from staff, service users, relatives and professionals involved with the home. The manager Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 23 advised that she intends to ask the advocates to assist service users in completing their questionnaires and the organisation is reminded to send a summary of the findings of the quality audit to the commission. Standard 40 was not assessed. The home was taken over by Sanctuary Housing in May 2006. However Sanctuary Housing policies and procedures have not been made available to the home. The manager confirmed that policies are gradually been replaced with Sanctuary Housing policies and this process should be escalated to ensure that staff are following the correct policies and procedures as required by Sanctuary Housing. As outlined in standard 35 all staff do not have the required mandatory training. One of the team leaders is responsible for overseeing health and safety at the home and care staff have delegated responsibilities regarding health and safety checks to support this. The home has excellent, well-organised and easily accessible health and safety records at the home which confirms that all health and safety issues are attended to. The health and safety records confirm that the gas safety annual check and fire equipment service is overdue and the team leader agreed to chase this up. A letter from the fire department to the Commission dated 5th July 2006 confirmed that a recent fire inspection of the premises had taken place and all was satisfactory. Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 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 2 X 3 X 3 X X 3 X Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 Requirement Service user plans must be developed to outline specific detail on the management of medical conditions, behaviours and situations. Service user plans including risk assessments must show evidence of service users involvement in their development and be kept updated & reviewed. The manager must contact the General Practitioner who prescribes rectal diazepam to agree a protocol for administration of this medication. If staff are required to administer this medication they must be trained and deemed competent by a suitably qualified Practitioner to do so. A written protocol must be put in place to outline the agreed procedure. Training on understanding and responding to challenging behaviour is to be made available to the staff team. (Previous timescale of the DS0000067532.V305481.R01.S.doc Timescale for action 30/09/06 2 YA6 YA9 15 & 13 30/08/06 3 YA20 13 15/08/06 4 YA32 YA35 18 30/08/06 Shaftesbury Court Version 5.2 Page 26 01/02/06 not met) 5 YA35 18 The organisation must ensure that all staff have the required up to date mandatory training. New staff must undertake this training prior to taking on specific tasks in relation to cooking and moving and handling. 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA2 Good Practice Recommendations The assessment documentation should be developed to include the date of the assessment, the signature of the individual carrying out the assessment and records of meetings and involvements of other professionals prior to admission. A programme of redecoration and renewal should be made available to the home to ensure that all areas of the home are kept maintained and updated. 2 YA24 Shaftesbury Court DS0000067532.V305481.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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. 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