Inspection on 26/09/06 for St Georges Road (67a)

This inspection was carried out on 26th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Georges Road (67a) 22/11/07

St Georges Road (67a) 26/01/06

St Georges Road (67a) 29/09/05

St Georges Road (67a) 03/02/05

St Georges Road (67a) 13/09/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 St Georges Road (67a) 67a St Georges Road Semington Melksham Wiltshire BA14 6JQ Lead Inspector Malcolm Kippax Key Unannounced Inspection 21st September 2006 1:55 St Georges Road (67a) DS0000028335.V311156.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.V311156.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.V311156.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 Vacant 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.V311156.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users who may be accommodated in the home at any one time is 3 Only the one, named, female service user currently being accommodated may be over the age of 65 years 26th January 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). 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 one member of staff working in the home and additional staff members are deployed at particular times of day. The home has its own vehicle for trips out. The scale of charges was described as ‘variable’ in information provided by the manager about the running of the home. Further details have been asked for in connection with this. St Georges Road (67a) DS0000028335.V311156.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, which took place on 21 September 2006 between 1.55 pm and 4.55 pm. A second visit was arranged with the home’s manager in order to complete the inspection. This took place on 2 October 2006 between 12.00 am and 3.30 pm. The home’s registered manager had left since the last inspection. Jane Pethers had been appointed to manage the home but had not yet made an application for registration. There were two service users living at the home at the time of this inspection, both of whom were met with on 21 September 2006. Evidence was obtained during the visits through: • • • • Discussion with the service users, staff members and the manager. Observation A tour of the accommodation. Examination of some of the home’s records, including the service users’ personal files. The manager was asked to complete a pre-inspection questionnaire although this was not received until after the visits. The OLPA Personnel Officer was asked about the recruitment process for a new member of staff. The judgements contained in this report have been made from the evidence gathered during the inspection, including the visits to the home. What the service does well: The two service users at 67a St. George’s Road have lived together for a number of years and have well established routines. Details of their day to day needs are recorded in individual plans, so that staff have the information they need when providing support. The service users talk with staff about what they want to do and are helped with making decisions. They choose what meals they would like and how they wish to spend their time. Some decisions have been recorded as personal goals, which set out the things that service users would like to do and receive support with in the future. Service users spend much of the week attending activities outside the home and have been supported with finding new things to do. This has been necessary because some of their usual activities have changed and may not be available in the future. One service user said that they now went to a different day centre, which they enjoyed. A staff member said that it was also hoped to arrange a new hydrotherapy session for this person. Other activities are to be followed up in connection with the service users’ personal goals. St Georges Road (67a) DS0000028335.V311156.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 on occasions to discuss things that affect them and to share any concerns with staff. Both service users need some assistance with personal care and with managing their medication. Guidance is provided for staff, which helps to ensure that service users have their needs met and that they are supported in a safe way. When at home the service users like to spend time in the own rooms which are well personalised. There is a spacious lounge and a separate dining room. Both service users said that they like the garden and during the visit on 21 September one of the service users was collecting pears from a large tree near the house. Overall, there is a homely feel to the accommodation, which looks clean, safe and well maintained. What has improved since the last inspection? What they could do better: Better information could be recorded about some of the service users’ personal goals. The goals included areas such as ‘keeping healthy and mobile’ and to ‘keep up leisure activities and holidays’. The timescale for achieving these goals was recorded as ‘on-going’. It was not always clear how achievement St Georges Road (67a) DS0000028335.V311156.R01.S.doc Version 5.2 Page 7 would be measured and what action should be taken, and by whom, in order to ensure that service users make good progress with achieving the goals. Risk assessments provided detailed information in areas such as behaviour, manual handling and the use of a bath hoist. These were kept on file with the care plans, although the link between the care plans and the risk assessments would be clearer if a system of cross-referencing was used. The home should look at increasing the opportunities for staff to attend external training events, in addition to the ‘in-house’ activities. This would help to widen staff members’ knowledge of learning disabilities and enable them to share good practice with people outside the organisation. It would be beneficial to review the arrangements being made for quality assurance to ensure that the views of service users are paramount and are reflected in the home’s development plans. 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. St Georges Road (67a) DS0000028335.V311156.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.V311156.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): EVIDENCE: These standards were not looked at on this occasion. No new service users have moved into the home for a number of years. The manager said that the Service User’s guide was currently being updated. The guide will need to include those items, such as details of fees and additional charges, which are specified in Regulation 5 of the Care Homes Regulations 2001. This regulation has recently been amended. St Georges Road (67a) DS0000028335.V311156.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 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visits to the home. Individual plans provide staff members with the guidance they need about the service users’ day to day needs. Information about the service users’ personal goals, and how these will be achieved, is less well reflected in their plans. Service users receive support with decision making and have individual lifestyles. EVIDENCE: The service users had individual care plans that included guidance about daily routines and the areas in which support is needed. Sections of the plans were dated to show when a particular area had been updated. The plans looked up to date, having been reviewed between June and September 2006. Written guidelines and risk assessments provided more detailed information in areas such as behaviour, manual handling and the use of a bath hoist. These were kept on file with the care plans, but there was no consistent system of crossreferencing in use. St Georges Road (67a) DS0000028335.V311156.R01.S.doc Version 5.2 Page 11 Other forms had been completed with information about the service users’ ‘Wants and Needs’, from which some personal goals had been recorded. The forms were also used for recording the service user’s progress with meeting their goals. The goals had been written in the last two months and covered a range of areas. One service user said that they were looking forward to having their room redecorated, but did not have a date when this would happen. This was recorded as being one of their goals. Other goals were more general, relating to areas of need such as ‘keeping healthy and mobile’ and to ‘keep up leisure activities and holidays’, where the timescale for achieving the goal was recorded as ‘on-going’. It was not always clear how achievement would be measured and what action should be taken, and by whom, in order to support the service user with achieving the goal. ‘Tenants’ meetings were being held, when service users commented about aspects of the home. The minutes of meetings held in June and August 2006 were seen. It was stated in the minutes that service users had said they are happy in the home and liked some changes that have been made. These included some new features in the garden and a new house vehicle. Assessments had been carried out for activities that may involve a degree of risk, such as using the home’s vehicle. Both service users required support from a staff member when outside the home, although there were occasions, such as shopping, when arrangements were made for a service user to exercise a degree of independence, with staff nearby. One service user said that they could be as independent as they wished to be. Service users were making decisions about what to eat, including the contents of packed lunches and the cooked evening meal. Their choice of meals was recorded each day in a house diary. During the visit, service users were choosing to divide their time between their own rooms and the lounge. When asked, one service user said that they couldn’t think of any house rules that applied. The manager said that more attention was being given to support service users with participating in their choice of activities outside the home. This was reflected in their personal goals, which included one service user’s goal, ‘to go out 1:1 and to experience new places’. A calendar in the dining room was being used to record the different things that service users had done during the month. St Georges Road (67a) DS0000028335.V311156.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 and 17 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visits to the home. Service users have regular activities during the week, which include participation in the local community. They are receiving support with finding new occupation. Service users receive support with their relationships and their rights are respected. Service users enjoy the meals. EVIDENCE: The service users attended day activities outside the home on four days a week and had one home-based day. The home-based day was an opportunity to receive support with domestic tasks and to have some one to one time with staff. The manager expressed concerns that some well established activities would no longer be available to service users, as the provision of day care was changing. The manager was aware of the need to look at alternative day activities and one service user had started attending a new day centre for part of the week. This service user said that they were happy with the change and St Georges Road (67a) DS0000028335.V311156.R01.S.doc Version 5.2 Page 13 liked visiting a new place. A staff member said that she was investigating the possibility of one service user attending a hydrotherapy session. One service user attended regular social activities outside the home, including P.H.A.B. and Gateway clubs. The other service user did not wish to attend these but did go on occasional outings and attended some ‘one-off’ events. This person had enjoyed a trip to the OLPA caravan in Weymouth and both service users had recently had a trip to Longleat. Both service users had personal goals recorded in the care plans about the need to maintain day activities and to find new opportunities. It was recorded in the minutes of a staff meeting in September 2006 that a service user was ‘to attend as many social functions as possible’ because of their reduced attendance at a day centre. Service users had different levels of contact with family and friends. One service user had frequent contact with a close relative who visited the home every week. One service user received support with maintaining a friendship that was made before moving into 67a St. Georges Road. Details of significant people and relationships were recorded in the service users’ individual files. One service user had recently received support with a visit to their parent’s grave. As reported at the last inspection, the two service users have not always enjoyed a positive relationship with each other. The manager reported that things were now more settled and that staff were looking to find ways in which a better relationship could be maintained. This was also reflected in the service users’ personal goals. The need for compatibility between service users will be very important consideration when looking at the suitability of a third person moving into the home. The main meal of the day was taken either at midday or in the evening, depending on service users’ day activities. Meals were chosen on a daily basis and a record kept of what the service users had eaten. The range of meals reflected the service users’ preferences and the type of food they liked. One service user said that they liked the breakfast that is made for them by staff, who also cook the other meals. The service user was particularly happy about this, although the other service user said that they liked cooking. A staff member said that one service user sometimes helps with the washing up, although generally service users did not get involved in the kitchen. A cordless phone is kept in the dining room, which service users can use in the privacy of their own rooms. One service user in particular had family and friends who they keep in touch with. St Georges Road (67a) DS0000028335.V311156.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 and 20 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visits to this service. Service users receive the support that they need with their health care and medication. EVIDENCE: The service users were registered with a GP at a local surgery. Both service users have had routine check ups that are available for people of their particular age and gender. Health care matters are reported in a section of the service users’ individual files and also discussed at staff meetings. The records showed that service users have had appointments with a range of healthcare professionals in recent months. One service user was reported to receive support from staff with toe nail cutting and the other service user had appointments with a chiropodist. Diet and the need to reduce weight had been discussed individually with service users and at ‘tenants’ meetings. One service user had a regular exercise schedule within home. New guidance on the use of the assisted bath has been produced since the last inspection. St Georges Road (67a) DS0000028335.V311156.R01.S.doc Version 5.2 Page 15 One service user felt that they managed most personal care tasks by themselves; they said that they just needed help with putting on socks. Service users receive support with the safekeeping and management of their medication. Both service users 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 and its administration were up to date. A form had been produced for the recording of PRN (as required) medication, although this was also being used to record a short course of medication that was prescribed for one service user. This inappropriate use of the P.R.N. form was brought to a staff member’s attention. 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. As previously recommended, some specialist input or an externally arranged course would also be beneficial in this area. Sine the last inspection, OLPA has produced a policy statement on gender and personal care. St Georges Road (67a) DS0000028335.V311156.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 and 23 Quality in this outcome area is good. This judgement has been made from evidence gathered during and after the visits to this service. Service users have the opportunity to raise concerns and are listened to by staff. Staff members receive training and guidance, which helps to protect service users. EVIDENCE: OLPA has produced a leaflet containing details of the organisation’s complaints procedure. Service users have been given a copy of the leaflet to keep in their rooms. The manager reported that no complaints have been received by the home in the last 12 months. The Commission has received no complaints about the service during this time. The ‘tenants’ meetings are used as a time when service users can air their views and talk about anything that concerns them. Both service users have regular contact with people outside the home. They mentioned people who they could talk to if not happy about something. Within the home, service users also have individual time with the manager or a member of staff. 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. The manager reported the there have been no adult protection investigations during the last 12 months. Abuse awareness is included in the OLPA staff training programme. St Georges Road (67a) DS0000028335.V311156.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 at least once during a 12 month period. 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 from evidence gathered during the visits to this service. The accommodation is homely and the garden is being well developed. The service users like their rooms and live in clean and domestic surroundings EVIDENCE: 67a St Georges Road is a detached bungalow set in large grounds and with a parking area at the front. The home is decorated and furnished in an ordinary, domestic style. The dining room has been redecorated since the last inspection. Both service users said that they were happy with their own rooms. These varied in size and had been well personalised. One service user was particularly pleased with the space in their room, which was large enough to be able to comfortably sit and spend time with visitors. There was a toilet and a bathroom near to the bedrooms. The areas of the home seen during the inspection looked clean and tidy. Support workers took the lead in the cleaning of the home and there were St Georges Road (67a) DS0000028335.V311156.R01.S.doc Version 5.2 Page 18 rotas and job lists for particular tasks, such as the kitchen. Key workers supported the service users with 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. During the visit on 21 September 2006, one service user spent time in the garden, collecting fallen pears. One part of the garden was being worked on to create a sensory area with a mix of different plants, wind chimes and textured surfaces. The manager said that is was the intention, over time, to develop other features and to make more of the garden accessible. St Georges Road (67a) DS0000028335.V311156.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate and improving. This judgement has been made from evidence gathered during and after the visits to this service. There is a small permanent staff team that meets the service users’ needs with support from relief staff and agency carers. The percentage of NVQ qualified staff is expected to increase shortly. Checks are being carried out which help to protect service users from unsuitable staff. Staff members receive in-house training in a range of areas. The benefits for service users have been reduced by the lack of an accredited programme of induction for new staff, although this is planned to change. EVIDENCE: The staff team included three staff members who had each worked in the home for a number of years. Two staff members were met with during the visit on 21 September 2006, one of whom said that she was shortly to retire. OLPA relief staff and two agency carers had worked a total of 13 shifts over an eight-week period. St Georges Road (67a) DS0000028335.V311156.R01.S.doc Version 5.2 Page 20 One staff member has achieved a National Vocational Qualification (NVQ) at level 2. The manager reported that two other staff members had also been doing their NVQ, which was being verified at the time of the inspection. The manager said that a new member of staff was due to start on a permanent contract in November. The home had a copy of this person’s Criminal Records Bureau disclosure, which included a check of the Protection of Vulnerable Adults (POVA) list. Other recruitment information was not available at the time. The OLPA Personnel Officer, who co-ordinated the recruitment process, said that two written references had been obtained for the new staff member. The manager reported that staff training during the last 12 months had included Person Centred Planning, First Aid, Administration of Medication, Food Safety, Fire Safety, Infection Control and Manual Handling. Details of these courses were included in a staff member’s individual training record that was looked at. This contained details of training that had been received up to the end of September 2006. Mandatory training is arranged on a cyclical basis; the manager said that further first aid training had been booked for December 2006. The majority of staff training was provided ‘in-house’, although staff have had places on an external course about ‘Death, Dying and Bereavement’. It was recommended at the last inspection that there is some external input into the training that staff members receive in medication procedures and drug usage. This would also apply to other areas of training, such as abuse awareness and vulnerable adults procedures. A staff member said that it would be useful to receive training in different communication methods and in dealing with challenging behaviour. f It was recommended at the last inspection that Learning Disability Award Framework (LDAF) accredited training is provided for staff who are new to working in a learning disability service. OLPA have since stated that they will be embracing the redesigned LDAF, which will enable the new Common Induction Standards to be applied with a learning disability context. The use of LDAF will also enable learning disability focussed knowledge materials to be available to staff to provide them with the underpinning knowledge needed for their NVQs. St Georges Road (67a) DS0000028335.V311156.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 at least once during a 12 month period. 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 from evidence gathered during and after the visits to the home. Service users are benefiting from the management arrangements that are in place, although the organisation has been slow to apply for the registration of a new manager. Improvements to the home are being identified. It would be beneficial to review the arrangements being made for quality assurance to ensure that the views of service users are paramount and reflected in a report. Suitable arrangements are in place for the health & safety of service users EVIDENCE: Jane Pethers has been managing 67a St. George’s Road since the registered manager retired earlier in the year. Jane Pethers is an experienced manager who is currently registered to manage another OLPA home, which was temporarily unoccupied. St Georges Road (67a) DS0000028335.V311156.R01.S.doc Version 5.2 Page 22 At the time of this inspection, the Commission had not received an application to register a new manager. Jane Pethers said that she had completed most of the application form for registration. The application needs to be made without further delay. Jane Pethers has achieved the Registered Managers Award and said that she was near to completing NVQ level 4 in care. A ‘Quality Assurance’ file was kept in the home. This gave details of how feedback was gained from service users and some outside parties. This included the ‘tenants’ meetings and a questionnaire that had been sent to stakeholders in July 2006. The manager said that she had not seen the outcome of this, although it was reported in the minutes of September’s managers’ meeting that the Commission was going to be sent a copy of the survey. There was a development plan for the home, which included several objectives for the coming year. These primarily focussed on improvements to the environment. It was unclear how the views of service users were contributing to annual development and service improvement. The manager reported that an Annual Development Plan for Quality Assurance was under review. The future arrangements will need to ensure that a system for quality assurance is maintained, which meets the requirements of Regulation 24 of the Care Homes Regulations 2001. This regulation has recently been amended and includes details of the type of report that needs to be produced in connection with the system. There were arrangements in place for the servicing and maintenance of equipment in the home. Portable appliance testing (P.A.T.) took place in May 2006 and an electrical wiring certificate was issued in the precious year. The assisted bath was last serviced in July 2006. Weekly in-house checks were being made of the home’s fire alarm system and hot water temperatures. A fire drill had last been held in July 2006. Radiators are covered, other than in the lounge and the dining room. It was reported at the last inspection that this continues to be raised with the housing association that owns the property. The manager said that the housing association had since written and confirmed that they would be fitting covers in these locations. C.O.S.H.H. information was kept on file. Risk assessments concerning the environment and lone working had been undertaken. Risk assessments relating to individual service users were kept on their personal files. St Georges Road (67a) DS0000028335.V311156.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 x 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 2 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.V311156.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 references are included in the service users’ care plans to show when risk assessments have been undertaken. That more specific information is recorded about the service users’ personal goals and how progress in achieving these will be measured. That service users are asked about their wish to be more involved in the preparation of food and drinks and, where appropriate, given opportunities to do this. That staff members are given more opportunities to attend external training events. That the arrangements being made for quality assurance are reviewed to ensure that the views of service users are paramount and are reflected in the home’s development plans. DS0000028335.V311156.R01.S.doc Version 5.2 Page 25 2. YA6 3. YA16 4. 5. YA35 YA39 St Georges Road (67a) Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 St Georges Road (67a) DS0000028335.V311156.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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