CARE HOME ADULTS 18-65
St Georges Road (67a) 67a St Georges Road Semington Melksham Wiltshire BA14 6JQ Lead Inspector
Malcolm Kippax Key Unannounced Inspection 22nd November 2007 11:55 St Georges Road (67a) DS0000028335.V351541.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 St Georges Road (67a) DS0000028335.V351541.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. St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Georges Road (67a) Address 67a St Georges Road Semington Melksham Wiltshire BA14 6JQ 01380 870168 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) Ordinary Life Project Association Jane Pethers Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (1) of places St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The maximum number of service users who may be accommodated in the home at any one time is 3 26th September 2006 Date of last inspection Brief Description of the Service: 67a St. Georges Road is one of a number of care homes that are run by the Ordinary Life Project Association (OLPA). The West Wiltshire Housing Association owns the property. 67a St Georges Road is situated in the village of Semington, between Trowbridge and Melksham. The property is a spacious, detached bungalow with a large garden. The service users have their own rooms. The communal areas consist of a lounge and a dining room. The service users receive support from a manager and staff team. There is always at least one member of staff working in the home. Additional staff members are deployed at certain times of day. The home has its own vehicle for trips out. Fee levels are in the region of £950 a week. A copy of the last inspection report can be obtained from the home or from the OLPA office at Beckford House, Gipsy Lane, Warminster, Wiltshire, BA12 9LR. Inspection reports are also available through the Commission’s website at: www.csci.org.uk St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home on 22nd November 2007 between 11.55 am and 4.10 pm. Evidence was obtained during the visit through: • • • • Time spent with the three service users. Meetings with the manager, Ms Jane Pethers and with a staff member. A tour of the home. Examination of records, including the service users’ care files. Other information has been taken into account as part of this inspection: • An Annual Quality Assurance Assessment (referred to as the AQAA) that was completed by the manager. The AQAA is the provider’s own assessment of how well they are performing. It also provides information about what has happened during the last 12 months. Surveys that were completed by two relatives and by two staff members. • The judgements contained in this report have been made from all the evidence gathered during the inspection, including the visit. What the service does well:
One service user had moved into 67a St. George’s Road since the last inspection. The home received good information about this person’s needs, so staff knew how the new service user should be supported and what they liked to do. The new service user had moved from another OLPA run home and was already known to the organisation. Staff from the service user’s former home had worked alongside staff from 67a St. George’s Road for a period of time. This had helped the person to settle in and enabled the staff team to gain more information about their needs. The other service users at 67a St. George’s Road had lived together for a number of years and had well established routines. Details of their day to day needs and preferences are recorded in individual plans, which helps to ensure that staff support people in a consistent way. The service users are helped with making decisions about what they want to do. They can choose the meals that they like and how they wish to spend their time. Some decisions have been recorded as personal goals, which set out the things that people would like to do and receive support with in the future. St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 6 Socially, the service users have different interests and tend to keep to their own routines. However they are encouraged to meet together each month to discuss things that affect them and to share any concerns with staff. People have the opportunity to attend activities in the community and to go out on a regular basis. They receive good support with maintaining their family relationships. This helps people to have fulfilling lives and provides them with more opportunities to do things outside the home. Relatives visit the home regularly and they feel confident about the service being provided. People in the home receive assistance with personal care and with managing their medication. Guidance is provided for staff, which helps to ensure that people’s needs are met and that they are supported in a safe way. Service users like to spend time in the own rooms, which they can decorate as they wish. There is a spacious lounge and a separate dining room. The home has a large garden, which has some interesting features and potential for further development. Overall, people live in homely surroundings and are well supported by the manager and staff team. What has improved since the last inspection?
Three people were living in the home at the time of this inspection. The admission of a third person during the last year has resulted in an increase in staffing levels. Ms Pethers said that this has been beneficial for all the service users, as they had been able to receive more support with their activities. One person in the home has received support from an advocate. This is particularly relevant because of the person’s communication needs. The advocate has been liaising with the home and with the service user’s family, in order to report on arrangements in the home from the service user’s point of view. There are large grounds around the home, which continue to be developed. The home won a prize for ‘Best improved garden’ in OLPA’s annual garden competition. One area of the grounds is now well established as a sensory garden. Some new features have been added during the last year. There is also a new seating area, which Ms Pethers said had been well used during the summer. Two people have chosen new colour schemes for their rooms. The lounge has also been redecorated and updated. This has given it a more modern appearance, which the service users like. Two staff members have achieved a National Vocational Qualification (NVQ) at level 2. Another staff member has completed their Learning Disability Award Framework (LDAF) accredited training.
St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 7 These qualifications and training help to ensure that service users are supported by competent staff, who are developing their knowledge of care practice. Ms Pethers has completed her NVQ in Care at level 4, so people in the home will benefit from having a well qualified manager. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Georges Road (67a) DS0000028335.V351541.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 St Georges Road (67a) DS0000028335.V351541.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including the visit to this service. People’s needs are assessed before they move into the home. EVIDENCE: One person had moved into 67a St. George’s Road since the last inspection. They had previously lived in another OLPA run home and were well known to the organisation. A decision was made, in conjunction with the service user’s placing authority, that 67a St. George’s Road would provide a safer and more appropriate home environment for this person. A number of review meetings had been held in connection with this before the move took place. The new service user’s personal file was transferred to the home, so that staff had the information they needed. Ms Pethers said that staff from the new service user’s former home had worked alongside staff from 67a St. George’s Road for a period of time. This had helped the person to settle in and enabled the staff team to gain more information about the person’s needs. St Georges Road (67a) DS0000028335.V351541.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including the visit to this service. People are well supported with their individual needs and with making decisions. People’s personal goals are well reflected in individual plans, although their progress with achieving these is less clearly identified. EVIDENCE: Each person had an individual plan that included information about their daily routines and the areas in which support was needed. Sections of the plans were dated to show when a particular area of support had been reviewed and updated. Written guidelines and assessments were providing more detailed information in areas such as behaviour, manual handling and the use of a bath hoist. These were kept on the service users’ individual files, but there was no system of cross-referencing being used to provide a link between the care plans and the assessments.
St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 11 The service users’ files contained other records that had been completed as part of the home’s system of person centred planning. People’s ‘wants and needs’ had been discussed with them, and a list of personal goals produced. The planning meetings had taken place within the last six months. Other forms were being used for recording people’s progress with meeting their goals and the date when they were achieved. Sometimes the goals were of a general nature, such as to go out on trips, or to ‘ensure social activities are on-ongoing’. In the case of the latter, it was stated that the frequency of activities would be monitored to ensure that they were at a manageable level. However it was unclear how progress with achieving the goal would be recorded and assessed. This was discussed with Ms Pethers, who said that activities would be recorded in the service users’ daily diaries. It was agreed that it would be useful to record the goal related activities on a separate form, as this could provide a better overview of what the person had done and how they had managed the activity. Other goals, such as having a bedroom redecorated, were more specific and had been achieved within a few weeks. Ms Pethers had reported in the AQAA that 95 of the service users’ goals during the last year had been met. Monthly meetings were being held when service users could keep up to date with arrangements in the home and discuss their daily routines. People talked about the meals that they liked and they could choose what to have. Their individual choices were recorded in a diary each day. An illustrated menu book had recently been produced to give ideas about meals and help people to choose. Assessments had been carried out for activities that may involve a degree of risk, such as going out in the home’s vehicle. Each person required support from staff when outside the home. However, there were occasions, such as shopping, when arrangements were made for a service user to exercise a degree of independence, with staff nearby. St Georges Road (67a) DS0000028335.V351541.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including the visit to this service. People have individual lifestyles and the daily routines are meeting people’s needs. EVIDENCE: People went to resource and day centres for part of the week and had other days that were home-based. The home-based days were an opportunity to receive support with domestic tasks and to have some one to one time with staff. Ms Pethers said that the admission of a third person during the last year had resulted in an increase in staffing levels. This had been beneficial for all the service users, as they had been able to receive more support with their activities. One person returned from a resource centre during the afternoon of the visit. Another person had arranged to go on a shopping trip with a staff member.
St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 13 Someone else went out with a close relative in the afternoon. Two service users had family members whom they usually saw each week and went out with. The relatives who completed surveys commented positively about their experience of the home and the service that people received. People looked well supported with their personal appearance. Mrs Pethers said that people visited a local hairdresser and received a good service from them. One person had an independent advocate. This was a relatively new arrangement. The advocate had looked at how well the home was meeting this person’s needs. They discussed this with the home and with the service user’s family. One service user said that they enjoyed going out socially. They had attended some clubs regularly. Another person did not wish to attend these but did go on occasional outings and had enjoyed attending some ‘one-off’ events. During the last year, service users have stayed in the OLPA holiday caravan that is situated on the south coast. A calendar in the dining room was being used to record the different things that service users had done during the previous month. Some people’s individual goals concerned their wish to do new things outside the home. Information was recorded on people’s files about their interests, family backgrounds and preferred routines. One person was able to visit the family grave at a nearby cemetery, which was important to them. It was reported that one person liked to spend time in the water and that they would enjoy going to a swimming pool, but were not currently doing this. Ms Pethers said that this was being followed up, with a view to finding a suitable facility. Service users chose their meals on a daily basis. One service user sometimes helped with the washing up, although generally service users did not get involved in the kitchen. There was a cordless phone that people could use in privacy of their own rooms, if needed. St Georges Road (67a) DS0000028335.V351541.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including the visit to this service. People’s personal care and health needs are met. Their medication is being safely managed. EVIDENCE: People had individual care plans, which showed the type of support that they needed from staff. One person was able to manage a lot of personal care tasks by themselves. There was a policy statement about personal care and the gender of staff members who provide support. A key worker system was in operation. Appointments with GPs and other health care professionals were being recorded, together with details of the outcome. Service users were having routine check ups that would be expected for people of their age and gender. Matters relating to the people’s health and welfare were being discussed at staff meetings. Mrs Pethers talked about one person’s admission to hospital earlier in the year, and the successful outcome of this. The service user concerned said that they had made a good recovery.
St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 15 Diet, and the need to reduce weight, had been discussed individually with people and at the ‘tenants’ meetings. One person had a regular exercise schedule within the home. Service users received support with the safekeeping and management of their medication. They had signed consent forms in connection with this. The home’s medication file included a range of relevant documentation and guidance for staff about the service users’ prescribed medication. Records of medication received into the home and of its administration were up to date. People’s medication was kept securely. GPs had signed the record of administration when a change had been made in the dosage of a particular drug. Staff members received in-house training in the medication procedures. It has been recommended at previous inspections that some specialist input, or an externally arranged course, would also be beneficial. St Georges Road (67a) DS0000028335.V351541.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including the visit to this service. The home’s procedures help to ensure that people are safe from abuse and that any concerns are followed up. EVIDENCE: OLPA has produced a leaflet containing details of the organisation’s complaints procedure. People had been given a copy of the leaflet to keep in their rooms. The procedure was not available in a range of formats. In their surveys, the relatives confirmed that they knew how to make a complaint if they needed to. Staff members also stated that they knew what to do if a concern was raised with them. It was reported in the AQAA that the home had received no complaints during the last year and there had been no safeguarding adults investigations. The Commission has received no complaints about the home during this time. The ‘tenants’ meetings were used as a time when people could air their views and talk about anything that concerns them. They also had regular contact with other people outside the home. There was written guidance in the home that referred staff to Swindon and Wiltshire’s procedure for the protection of vulnerable adults. A staff member confirmed that she had been given her own copy of the ‘No Secrets’ guidance booklet. Abuse awareness was included in the OLPA staff training programme.
St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including the visit to this service. People live in homely surroundings that meet their needs. EVIDENCE: 67a St George’s Road is a detached bungalow set in large grounds and with a parking area at the front. The home was decorated and furnished in an ordinary, domestic style. Two people’s bedrooms had been decorated during the last year. They had chosen new colour schemes for their rooms. The lounge has also been redecorated and updated. This has given it a more modern appearance, which the service users like. Service users said that they were happy with their own rooms. These varied in size and had different outlooks. There was a toilet and a bathroom near to the bedrooms. St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 18 The accommodation looked clean and tidy. Staff members took the lead in cleaning the home. There were rotas and lists for particular tasks, such as jobs that needed to be done in the kitchen. Key workers supported people with looking after their own rooms. There was a utility room with laundry facilities off the kitchen. Assessments had been undertaken in respect of some environmental risks and guidelines on infection control were available. There were large grounds around the home, which continue to be developed. The home had won a prize for ‘Best improved garden’ in OLPA’s annual garden competition. One area of the grounds was set aside as a sensory garden. Some new features had been added during the last year. There was also a new seating area, which Ms Pethers said had been well used during the summer. Ms Pethers said that the home was experiencing difficulties in getting some maintenance items completed, when these were the responsibility of the housing association that owns the property. Ms Pethers said that letters had been written about this to try and improve the speed at which the work is completed. The home was waiting for the front porch to be refurbished and also for some work to be carried out in the kitchen. St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including the visit to this service. People are well supported by competent staff. EVIDENCE: The staff team normally included three permanent staff members. However, one person had left shortly before this inspection and there were temporary arrangements in place until a new staff member could be appointed. A checklist was kept in the home, which showed the recruitment process that had been followed. In their surveys, the staff members confirmed that checks, such as CRB (Criminal Records Bureau) and references, had been carried out before they had started work. They also thought that their induction had covered everything that they needed to know when they started. Two staff members had achieved a National Vocational Qualification (NVQ) at level 2. One staff member has completed their Learning Disability Award Framework (LDAF) accredited training during the last year. Each staff member had an individual training and development plan. St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 20 OLPA provided staff with a programme of training. This mainly concerned a range of mandatory subjects, which included First Aid, Administration of Medication, Food Safety, Fire Safety, Infection Control, Abuse Awareness and Manual Handling. Staff members also had the opportunity to attend some skills related training events in subjects such as communication and mental health awareness. The majority of staff training was provided ‘in-house’. It has been recommended at previous inspections that the training programme is developed to include a wider range of subjects and types of training. This would be particularly beneficial for staff members who have been employed for some years and whose training had mainly been limited to attending the mandatory courses. During the visit, a staff member confirmed that she had received all the mandatory training and was waiting to attend an external course about ‘Death, Dying and Bereavement’. St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including the visit to this service. People benefit from a well run home. EVIDENCE: Jane Pethers is an experienced manager who came to 67a St. George’s Road from another OLPA run care home. Ms Pethers has achieved the registered managers award and since the last inspection has completed a National Vocational Qualification (NVQ) in Care at level 4. A ‘Quality Assurance’ file was kept in the home. This gave details of how quality assurance was managed in the home and how feedback was gained from service users and other parties. There was a home development plan for 2007 – 2008. St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 22 This focussed on improvements to the environment, staff training, and the service users’ activities. It was stated in the plan that the service users, staff and relatives have completed surveys. However it was not clear how their views had contributed to the annual development plan and the improvements identified. There were arrangements in place for the servicing and maintenance of equipment in the home. Portable appliance testing (P.A.T.) took place annually. The bath hoist was last serviced in September 2007. A fire risk assessment had been undertaken in June 2007. C.O.S.H.H. information was kept on file. Assessments had been carried out in other areas, such as lone working, infection control and the use of kitchen utensils. Risk assessments relating to individual service users were kept on their personal files. The home was using the ‘Safer food, Better business’ log book for the recording of food safety and other kitchen checks. St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations That a system of cross-referencing is used in the service users’ individual plans to show when risk assessments have been undertaken. This is so that the all the relevant information in respect of a particular need is more readily identified. That the service users’ progress with achieving their goals and future plans is more consistently monitored and recorded. This will help ensure that service users make the progress that they are capable of and that the goals continue to be relevant. That the home should look at different ways in which service users can be given information, for example about the complaints procedure. This is in order to make it easier for the service users to understand the information that they are being given. 2. YA6 3. YA22 St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 25 4. YA35 That the home’s plan for staff training is developed to include more specialist areas of training, involving outside agencies. This will help ensure that service users benefit from staff members who have attended a wider range of training types and courses. That the home’s annual development plans show how service users and their representatives have been involved and made a contribution. This would help ensure that their views are being taken into account and acted upon. 5. YA39 St Georges Road (67a) DS0000028335.V351541.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA 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
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