Inspection on 12/09/06 for Stokewood

This inspection was carried out on 12th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stokewood 14/12/05

Stokewood 20/06/05

Stokewood 14/02/05

Stokewood 10/08/04

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

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

CARE HOME ADULTS 18-65 Stokewood 204 Hunts Pond Road Titchfield Common Fareham Hampshire PO14 4PJ Lead Inspector Laurie Stride Unannounced Inspection 12th September 2006 09:30 Stokewood DS0000055847.V311151.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 Stokewood DS0000055847.V311151.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. Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stokewood Address 204 Hunts Pond Road Titchfield Common Fareham Hampshire PO14 4PJ 01489 603108 01489 557289 stokewood@truecare.co.uk 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) Truecare Group Limited Michaela Dawn Russell Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 2005 Brief Description of the Service: Stokewood is part of the Truecare Group managed by C.H.O.I.C.E. Ltd. providing residential accommodation for up to seven women who have mental health issues. Stokewood offers seven single bed rooms all with an en-suite toilet and shower facilities The home is situated on the outskirts of Fareham, along a busy residential road. The property is detached with parking spaces at the front, and a large established garden to the rear. Community facilities can be accessed by foot, using public transport, or through use of the home’s vehicle. The current range of fees (Client Contributions) is: £1,730.96 - £2,447.51 per month. Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection visit was carried out on 12/09/06 and lasted approximately seven hours. During this time the inspector met and spoke with four of the ladies who live in the home, two staff members and the registered manager. A tour of the premises was undertaken and samples of documents held in the home were seen. People living in the home prefer to be referred to as the ladies rather than service users or residents. Therefore, for the purpose of this report when referring to people who live in the home, the term ‘ladies’ has been used. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 6 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 Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 7 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&5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place to assess each lady’s needs and aspirations prior to admission. However, the procedures for admitting people to the home need to be improved to ensure that their needs can be fully met once they have moved in. EVIDENCE: The home had completed its own initial contact form for one lady who had moved in during the last year. This gave a brief history of the person and an assessment of their skills, hobbies, health, behaviour and associated risks. This lady had also been asked and supported to provide her own report about herself, including personal hygiene, sleeping, hobbies, relationships, dressing, clothes, food likes and dislikes. The home had also obtained an assessment and guidelines from the individual’s previous placement. Staff from the home had also attended two of this lady’s Care Plan Approach (CPA) review meetings at the previous placement prior to admission to Stokewood. The registered manager said that since this lady had moved in, the home had been unable to access professional mental health support for her from local agencies. This was due to circumstances that were discussed. Evidence was seen that this lady’s GP had also written to a relevant authority stating that an urgent review of this lady’s needs was needed. (See also the section on Personal and Healthcare Support). Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 8 The manager feels that the home has been able to meet this lady’s needs, has enabled her to develop and says they have received positive feedback from her and her social worker and GP, but is aware of her need for professional specialist backup. The home needs to ensure that individual healthcare arrangements are adequate before people are admitted. Contracts specifying the terms and conditions of residence for people living at Stokewood were seen on file. Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most of the ladies’ assessed needs and changing goals are reflected in their care plans, and they are supported to make decisions and take risks as part of their independent lifestyles. However, not all of the ladies needs have been adequately reviewed and recorded. EVIDENCE: A sample of three of the ladies’ care plans was seen. The ladies had signed their own care plans and help to complete the daily report at the end of the day. The ladies also maintain personal appointment files such as G.P. reviews, making a record of how they felt meetings went. The home operates a system of key-teams of workers who assist individual ladies’ in evaluating their progress and reviewing their needs and aspirations. The ladies meet with their key-workers every month and this is recorded. There were also copies of sixmonthly Care Plan Approach (CPA) reviews involving relevant health care professionals for two of the sample group. As already mentioned, one lady has not had a review and currently has no access to professional mental health care outside of the home and organisation. A full up-to-date assessment of her needs is required in order to ensure that the home can meet those needs Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 10 and additional specialist support is made available. Evidence was seen that the home is actively seeking to address this issue. The ladies’ care plans are based on a needs/objectives/method approach format. Each file contained records of monthly evaluations, night checks if necessary, daily observations of behaviour and physical health. The registered manager demonstrated how she was developing care planning with Independence Files for individual ladies. An example of this person centred approach had a support network of a lady’s chosen contacts and plans for developing life skills. Independent living skills such as shopping, meal planning and doing the laundry are broken down into details or steps in accordance with the needs of the individual. The person records, with assistance if required, their personal goals and how they feel about coping with independent skills. Some of the ladies were observed being involved in the running of the home and in choosing the activities that they participate in. Each lady retains a copy of their personal care plan and weekly timetable of agreed activities. Staff members were seen providing the ladies with information and support to make decisions about their lives. The ladies are supported to manage their own finances and this was also observed and records are kept of the management of personal allowances. Following a number of incidents the home had fitted window restrictors and an electric fan in one lady’s bedroom. The two side gates of the house had recently been boarded to prevent them being climbed and a keypad fitted to one to enable access to those ladies who were assessed as being able to safely go out alone. This was not recorded in one relevant care plan and the manager said that the restrictions had been put in place as a temporary measure to ensure the person’s safety, also that she had asked the company to provide top-opening windows in this lady’s room. It was advised that any physical restrictions or limitations placed on a person’s right to make decisions must be detailed in their care plan. The manager said she would do this. Individual risk assessments were on file for each lady including guidance for staff on managing unsettled or extreme behaviours. Further information included behaviour observation charts and indicators. Risk assessments also covered activities such as community access, use of the kitchen/cooking and managing money, in order to promote people’s independence. Incident forms are completed for any incident with a record of action taken. Examples seen of these included physical restraint but the form did not clearly detail what kind of restraint. A separate form is used for this purpose, but the manager explained that these records were usually sent to the Physical Interventions Manager. It was advised that the home retains a copy of all such records for inspection and analysis and that times/durations of restraint are always clearly recorded in the appropriate boxes. Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 11 Stokewood DS0000055847.V311151.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 this service. The ladies benefit through the home providing opportunities to take part in suitable activities, access the community and maintain relationships. The ladies rights and responsibilities are recognised in the daily routines of the home and meal planning promotes choice and healthy eating. EVIDENCE: The ladies had access to and took part in a range of activities and this was confirmed through discussion with staff and some of the ladies. The ladies receive a holiday entitlement as part of their funding agreements and choose to use this in a variety of ways, for example going on holiday in Wales, Butlins, outings to Chessington and visits to museums, theatres and shows. Each lady has a bicycle. As indicated in the previous section, the ladies are provided with a range of skills development opportunities within the home. The ladies have individual weekly timetables and some of these included going to college, visiting the Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 13 library and accessing the community. The home also provides support through identifying part-time job opportunities, which some ladies have taken up. Some of the ladies talked about shopping locally and further afield and the organisation had recently provided the home with a new people-carrier. The ladies used other local facilities, for example one said she liked to visit a pub and another had joined a social club. The manager said that they received invites to ladies’ evenings held at the nearby school and all of the ladies received their election cards to use should they choose to vote. The home’s visiting policy states no overnight stays but otherwise is flexible and visitors can stay for a meal if the ladies wish. One lady was away on a home visit with her relatives and another lady confirmed they received visitors in the home. There is a written organisational policy on providing support with regard to people’s sexuality and relationships and staff at the home provide practical and emotional support. The manager confirmed that external professional advice and guidance could be accessed as required, for example care managers and advocates. There are written house rules and each lady is given a copy and made aware of these prior to deciding to live at Stokewood. Some of the ladies were observed participating fully in the daily routines of the home and picking up their own mail. Housework tasks are clearly scheduled and form part of each lady’s timetable of activities, which promote responsibility and independence. Each lady has a key to their bedroom and may have a house key, subject to assessment. Staff and ladies were observed interacting throughout the visit and the ladies could choose when to be alone or in company and when not to join an activity. People are allowed to keep pets and the home currently accommodated two cats, a hamster and a guinea pig. Smoking for the ladies and staff is restricted to outside the house. The inspector had lunch with the ladies and staff, which was relaxed and informal and provided evidence that people felt free to express themselves openly. The ladies write up their own food menus and staff provide support and advice to promote healthy eating. Records of people’s individual food and drink intake are kept and special diets are catered for. The registered manager said that the previous evening staff and the ladies had gone for a meal by the waterfront. Stokewood DS0000055847.V311151.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 this service. Staff members treat the ladies with respect and encourage their independence. The majority of the ladies have access to health care services that meet their assessed needs, and the home is actively seeking to address a lack of specialist support for one lady. The home’s policies and procedures ensure the safe administration of the ladies medication and promote their independence. EVIDENCE: Through observation and conversation with some of the ladies and staff it was evident that the ladies received individual support in line with their preferences. All choose when to get up and what clothes to wear. Daily routines and programmes of activities are flexible to promote the ladies independence and control over their lives. Staff members were seen working with the ladies in a way that upheld people’s privacy and dignity. Through the sample of care plans, other records seen and discussion with the registered manager, it was evident that all but one of the ladies currently had access to relevant health care services. For the majority of people there was evidence of six-monthly Care Plan Approach (CPA) reviews involving relevant health care professionals, consultant appointments, health and medication monitoring at regular clinics. All the ladies have access to a GP, dentist and Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 15 chiropodist. Health information forms record the ladies appointments and outcomes, for example medication reviews. The registered manager was aware of one lady’s need for professional mental health support, particularly in the wake of a number of incidents involving unsettled behaviour, and reported that the home had made attempts to access this support. A letter from this lady’s GP to the funding authority supported the manager’s statement and arrangements were underway to clarify this lady’s diagnosis and who is responsible for providing the support. This lady was very positive in her comments about the manager and staff and the support she received from the home. The home has a written policy and procedure for handling medication and uses a monitored dosage system to hold and administer medication. The ladies are encouraged and assisted to manage their own medication and staff members record when medication is taken. Care plans and risk assessments are in place for this. There are clear guidelines on record showing staff when to administer medication and what individual drugs are for. Some of the ladies may have ‘medication as required’ and there were guidelines and indicators for staff to follow when giving this, including contact numbers of healthcare professionals and management. Records showed that staff received training in relation to medication. Medication is stored securely in a purpose built cabinet. Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has effective systems for ensuring that the ladies views are listened to and responding to any complaints. The ladies are protected by the home’s policies and procedures for responding to any form of abuse. EVIDENCE: The home’s complaints procedure is contained in the Statement of Purpose and the Service Users’ Guide and in the ladies personal files. The Commission for Social Care Inspection (CSCI) had been informed of one ongoing complaint that the home was dealing with and records of this were on file showing the home’s response. There had been no complaints from the ladies or their representatives. An open and inclusive atmosphere was evident in the home, which would contribute to people feeling free to talk about any concerns. The home has a copy of the local authority adult protection procedures. Staff members receive training in adult protection issues as part of their induction and two staff members demonstrated through discussion that they understood the procedures for reporting and recording any allegations or suspicions of abuse. There is an organisational policy regarding the use of physical interventions and records are kept of instances when it has been necessary for staff to restrain people. As mentioned in a previous section, it is advised that the home retains copies of the records that show details such as the type and duration of restraint. Procedures for using restraint were discussed with two members of staff, who both demonstrated their knowledge and understanding of not only the procedures but of individuals who may require restraining. Staff Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 17 said they were offered support sessions following incidents and that the initial training in physical interventions lasts four or five days and is renewed each year. (See also section on Staffing: training). There had been instances where the registered manager had acted in the role of an appropriate adult. It was advised that this arrangement was explained in the Service User Guide. The ladies were observed having easy access to their personal allowances, which are held securely by the home. The home keeps records of transactions that are signed by the individual lady and staff member on duty. Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The ladies benefit from living in an attractive, safe, clean and comfortable environment. EVIDENCE: The home was bright and well ventilated and equipped with good quality furniture and fittings. Bedrooms were decorated according to each ladies own preferences and one lady confirmed this. All rooms contain en-suite facilities and had been personalised with the occupant’s belongings. Communal areas were attractive and spacious, including a well-maintained garden that had been designed with reference to specialist guidance. The ladies each have their own drawer in the kitchen and a locker for personal items in the laundry room. The laundry area is equipped with modern appliances that the ladies are supported to use independently. Infection control training for staff is provided. As mentioned in a previous section, both side gates had been boarded for safety reasons. This detracts from the overall attractiveness of the environment and consideration should be given to providing a suitable alternative that promotes people’s safety and dignity. Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 19 Hampshire Fire and Rescue Service conducted a safety audit of the premises on 26/06/06 and found the fire safety standards were satisfactory. Stokewood DS0000055847.V311151.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, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The ladies receive support from an effective, well-trained and supervised staff team and the home supports and encourages staff to undertake relevant care qualifications. The ladies are protected by the home’s staff recruitment procedures, however better documentation is needed in relation to this. EVIDENCE: A sample of the home’s staff recruitment records was seen in relation to four staff members. The organisation has an agreement with CSCI that the original documents are held centrally and the information is transferred to a form that is held in the home for inspection. The information seen indicated that the organisation carried out required checks on staff before they worked with the ladies in the home, such as Criminal Records Bureau (CRB) and POVA (Protection of Vulnerable Adults). Also that new staff completed application forms with employment histories. However, two out of the four staff forms did not provide evidence that two written references had been received in respect of each staff member. The manager said she would obtain the necessary information. It is a requirement that the home maintains complete records of all the necessary checks carried out on each staff member, in order to evidence that people are protected by the organisation’s recruitment procedures. Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 21 There are currently six ladies living at the home and staffing levels were observed to be sufficient to support the ladies assessed needs. In addition to the registered manager, there are usually four staff members on shift during the day and three at night, one of who is asleep. The registered manager reported that staffing levels are flexible around the numbers, needs and circumstances of people accommodated in the home. The ladies gave positive comments about the staff team. The organisation has its own training department and a comprehensive staff training and development plan was seen. This gave a clear record of training attended by each member of staff and when updates were due. New staff members receive structured induction and foundation training including Certificate of Mental Health level 2, Obsessive Compulsive disorder, Depression, Personality disorder and Schizophrenia. Staff members are also given training in breakaway techniques, management of violence, risk assessment, adult protection and mandatory health and safety courses. NVQ level 2, 3 and 4 and Certificate of Mental Health level 3 are also provided as part of the rolling programme. The registered manager had a file of recently implemented additional in-house staff training, which included care planning with the ladies, knowledge of the ladies (a staff questionnaire), understanding medication and records, understanding risk assessments, planning healthy menus, the fire alarm system and other subjects. Through discussion with two staff members it was confirmed that relevant training had been provided during the induction period and both said the training was good and had increased their knowledge and confidence. Staff members felt that they were part of a close team and that they had back-up and demonstrated knowledge and understanding of the ladies needs. As mentioned in a previous section, the registered manager was aware of one lady’s need for professional mental health support, which could not be provided by staff in the home. There are established arrangements for staff supervision and these were confirmed through records and discussion with staff. Comments from the staff and ladies indicated that the home’s manager was always accessible and supportive. Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The ladies benefit from a generally well run home that seeks their views and promotes the health, safety and welfare of the ladies and staff, which will be greater enhanced once the requirements made have been met. EVIDENCE: The registered manager has completed the Registered Managers Award (RMA) and is awaiting the outcome of her NVQ level 4. Throughout the inspection visit it was observed that the management approach of the home creates an open, positive and inclusive atmosphere. Good working relationships exist between the staff group and the ladies and staff. One lady gave very positive comments about the manager of the home. The requirements identified in the relevant sections of this report, in relation to improving the admissions process to ensure that peoples’ needs are fully met once admitted, care planning reviews and ensuring adequate access to Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 23 professional healthcare, need to be addressed. Better record keeping in respect of staff recruitment checks is also needed. The organisation operates a quality assurance system that includes anonymous questionnaire surveys sent out to people who use the services, their next-ofkin, care managers and staff. The results of the most recent of these had been evaluated and given to the manager who had subsequently written a draft development plan for the home, which was seen. The home also obtains the ladies views through group discussions, often at mealtimes, which are recorded. Regular staff meetings are also held and recorded. As mentioned in the previous section, staff members receive training and updates in mandatory health and safety subjects as part of the rolling programme of training. This includes First Aid, Moving and Handling, Food Hygiene, Fire Safety and Infection Control. A designated member of staff carried out the weekly fire alarm test at the time of the visit. The home had recently undergone major building works and refurbishment and the manager keeps a file of up-to-date certificates relating to tests and services of equipment and appliances, such as gas, electric and fire safety systems. (This was seen). The home had the new version accident book and this was being completed correctly. Stokewood DS0000055847.V311151.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 3 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 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 3 X 3 X 3 X X 2 X Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14(1) Requirement The registered person must ensure that only people whose assessed needs can be fully met are admitted into the home. The registered person must ensure that the assessed needs of each person who uses the service are kept under review. The registered person must ensure that each person who uses the service has access, where necessary, to treatment, advice and other services from any health care professional. The registered person must ensure that staff recruitment records or pro-forma as agreed with CSCI must be held in the home with all required information. Timescale for action 12/12/06 2. YA6 14 (2) 12/12/06 3. YA19 13 (1) (b) 12/12/06 4. YA34 19 (1) (b) Schedule 2 12/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Stokewood Refer to Good Practice Recommendations DS0000055847.V311151.R01.S.doc Version 5.2 Page 26 Standard Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Stokewood DS0000055847.V311151.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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