Inspection on 19/06/06 for Swan Bank

This inspection was carried out on 19th June 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

Swan Bank 25/07/07

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Swan Bank 2 Swan Bank Penn Wolverhampton West Midlands WV4 Lead Inspector Rebecca Harrison Key Announced Inspection 19th June 2006 09:55 Swan Bank DS0000065428.V293076.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 Swan Bank DS0000065428.V293076.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. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Swan Bank Address 2 Swan Bank Penn Wolverhampton West Midlands WV4 01902 557 995 01902 557 996 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.wolverhampton.gov.uk Wolverhampton City Council Miss Ann Watson Care Home 4 Category(ies) of Learning disability (0) registration, with number of places Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No conditions apply Date of last inspection N/A – New service Brief Description of the Service: Swan Bank is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and short-term care for a maximum of four adults with a learning disability at any one time. The home currently provides a service for 16 people over 364 days a year. Referrals are made through the Community Learning Disability Team based at 44 Pond Lane, Parkfields, Wolverhampton. The property is purpose built, opened in 2005 and comprises a lounge, dining room, kitchen, 4 bedrooms (to include a bedroom located on the ground floor) a bathroom and a small garden. Two of the bedrooms have en-suite facility to include one with an overhead tracking device. The premise is also used as a base for independent living training, skills assessment and therapeutic intervention. The service provider is Wolverhampton City Council. The Responsible Individual is Mr Brian OLeary, Chief Adult Care Officer and the Registered Manager is Ms Ann Watson. The premise is situated in Penn, close to local amenities and on the outskirts of Wolverhampton City Centre. The aim of the service is included in the Statement of Purpose and states ‘the service is to enable people with a Learning Disability and/or specific behavioural need, to access a range of short break and support services designed to assist and promote independence’. The fees charged per person per overnight stay range from £8.91 to £13.49. The charge for the outreach element of the service varies in accordance with individual financial assessments. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and commenced at 09.55 a.m and lasted 5.5 hours. The inspection included discussions with the manager and two support staff on duty and the cook, examination of a number of records and a tour of the environment. At the time of the inspection all service users were out accessing local day services. All 22 key National Minimum Standards for younger adults were assessed in addition to Standards 1,5,14,36 and 41 and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The manager and staff on duty were welcoming and fully co-operated throughout the inspection. The purpose of this unannounced inspection was to review the progress made since the home was registered on the 20th October 2005. One complaint has been received by the service and this was upheld and satisfactory action taken by the provider. No complaints have been referred to the Commission for Social Care Inspection. There have been no referrals made under adult protection procedures. What the service does well: What has improved since the last inspection? This is the first inspection undertaken since the service was registered on 20th October 2005. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 6 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. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place that would enable the successful admission to the service. EVIDENCE: A comprehensive Statement of Purpose has been developed and includes the information as required under Schedule 1 of the Care Homes Regulations 2001 with the exception of room sizes. A Service User Guide remains outstanding. The criteria for admission to the service is included in the homes Statement of Purpose in addition to the service specification and terms and conditions. The manager provided the inspector with a good overview of the service provided including the assessment procedure and the referral process. Comprehensive pre-admission assessments were available on the files reviewed. Staff spoken with reported that trial visits are always undertaken prior to admission to the service, however they expressed concern in relation to the service meeting the needs of two new referrals given the limited communal space available. The manager acknowledged this at the time of the inspection. A signed copy the terms and conditions were available on the two service user files reviewed. Swan Bank DS0000065428.V293076.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care-planning systems are in place to adequately provide staff with the information they need to satisfactorily meet service users assessed needs. Service users are appropriately supported with decision-making making processes and enabled to take responsible risks within a risk-assessed framework. EVIDENCE: The care documentation of two people in receipt of a service at the time of the inspection was reviewed at length. A Summary of Assessed Needs and Service User Plan were available and the information was comprehensive. Staff spoken with during the inspection confirmed that they are provided with sufficient information to appropriately support the individuals concerned. Records seen evidence that support plans are reviewed on a monthly basis and any changes clearly recorded. Day service reviews were also available on file. A copy of the review dates for all service users was available. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 10 Rights, choices and the arrangements made for consultation with service users are included in the homes Statement of Purpose. Each service user is allocated a key worker who’s responsible for drawing up the individual plan with the service user and family member if appropriate. The key worker also advocates on behalf of the individual if required. It was reported that the service liaises closely with a range of day services that people access throughout their stay at Swan Bank. Numerous risk assessments were seen on the files of the two people case tracked. These were individualised, comprehensive and enable people to take responsible risks in accordance to their needs. A risk assessment for one individual for accessing the homes bathing facilities required updating however the manager immediately actioned this during the inspection. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 11 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): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to attend their usual social activities throughout their stay and have a community presence. Family links are maintained, rights and responsibilities promoted and people provided with a varied and balanced diet in accordance with their personal preferences. EVIDENCE: It is the expectation that people accessing Swan Bank continue to attend their usual day service provision provided by the local authority during their short stay. The service users accommodated at the time of the inspection were out accessing a range of local day services. Swan Bank is unable to provide permanent full time placements therefore it is not appropriate for staff to seek employment opportunities for service users or to deal with the management of peoples benefits. It was reported that the people accessing the service may continue to attend their usual evening clubs and social events if required and transport is Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 12 provided to enable this. Preferred activities were documented on the service user plans reviewed and daily records maintained. A record of all activities undertaken was seen on individual ‘evaluation of stay’ record. Staff spoken with also informed the inspector of the opportunities provided which promote an active community presence and participation. It was reported that although service users are on respite they may if desired maintain contact with family and friends and visitors to the service are always welcome. A leaflet inviting people to attend forthcoming coffee mornings was seen displayed. The rights of residents are clearly stated in the Statement of Purpose, which include the right to be treated as an individual with unique needs and have their cultural, religious, sexual and emotional needs accepted and respected. People staying overnight at the service have sole use of their bedroom. Bedroom doors are lockable in order to provide privacy to service users. Keys are provided based on a risk assessment. It was reported that none of the current service users choose to smoke. Preferred routines were seen in service user plans and assessments. The menus seen during the inspection appeared well balanced and offered choice. During a tour of the kitchens fresh fruit and vegetables were seen readily available. The home has a designated cook and staff spoken with were very complimentary regarding the meals provided. Discussions held with the cook during the inspection indicate the service is able to cater for a range of cultural and dietary needs of the people in residence. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 13 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 using available evidence including a visit to this service. Service users’ health care needs are closely monitored and personal support provided according to individual assessed needs. The management of medication is effective. EVIDENCE: The manager reported that people using the service continue to have their health care needs met by their own general practitioner and/or any other health care professional involved. However arrangements are in place for service users to be seen by the local general practitioner if required. Staff are available to support an individual to any medical appointment during the stay at the home as required. ‘Evaluation of Stay’ records were seen on the files of the two people case tracked and covered the general well being of individuals during their stay. As previously stated staff on duty confirmed that they have sufficient information for care delivery and personal care is provided according to preadmission assessments undertaken and the service user plan drawn up by the allocated key worker. Arrangements for respecting privacy and dignity is included in the homes Statement of Purpose and staff spoken with provided Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 14 the inspector with clear examples of how privacy and dignity is promoted within the service. The manager reported that Health Action Plans are currently on hold as the local Community Learning Disability Team, based at Pond Lane are currently revamping the paperwork. At the time of this inspection it appeared that medication was being administered, recorded and secured satisfactorily and six staff in addition to the manager have undertaken distance learning accredited medication training. The manager reported that a further five staff are currently undertaking the training and the remainder of the staff will enrol on the course shortly. The manager also observes staff competence. CSCI received notification in January 2007, under Regulation 37 regarding a medication error and the necessary action was taken in relation to this. The manager has also sought advice from the CSCI’s Pharmacist Inspector regarding medication practices when supporting people out on day trips. It was reported that none of the current people accessing the service self administer their medication or are currently prescribed controlled drugs however the home has appropriate storage facility and a controlled drugs book is available. A staff member was observed working on course work relating to the distance learning medication training during the inspection. A record of staff authorised to administer medication was seen at inspection. The homes medication policy was not reviewed on this occasion however Wolverhampton City Council (the registered provider) has consulted CSCI Pharmacist Inspector in relation to the policy and medication practices in other registered care homes across the City. An agreement for covert administration of medication was seen on the file of one person case tracked, signed and dated by the parent, general practitioner, pharmacist and registered manager. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 15 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 using available evidence including a visit to this service. The home has a complaints procedure in place and systems to safeguard service users from any potential abuse. EVIDENCE: The local authorities guide to making a complaint for people with learning disabilities was seen available. The manager confirmed that one complaint has been received since initial registration of the home. The complaint was upheld and the documentation shared with the inspector. There have been no complaints received by CSCI in relation to the service and no referrals have been made under adult protection procedures. Staff spoken with confirmed that they have received appropriate training on the local protection of vulnerable adults policy and procedures. The manager reported that the majority of staff have now undertaken adult protection training. The finances held at the home for one individual were checked by the inspector and were an accurate reflection of the records held. Security tags are used on service users wallets, receipts of all expenditure held and two signatories seen for all transactions made. It was reported that support staff have undertaken training on the Management of Potential and Actual Aggression (MAPA). The manager reported that no service user has been subject to physical intervention. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 16 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 using available evidence including a visit to this service. The standard of the environment is good providing service users with a safe and comfortable place to stay. EVIDENCE: It was evident through a full environmental tour undertaken that people accessing this service are provided with a comfortable, safe and well equipped place to stay. Rooms were bright, clean and airy and free from offensive odours. Rooms were not measured on this occasion and measurements are not detailed in the homes Statement of Purpose. People using the service are provided with single bedrooms, two of which have en-suite facility. Wash hand basins are provided in rooms without en-suites. The ground floor bedroom provides facilities for a wheel chair user with overhead tracking device installed in the shower room. A passenger lift is also available to aid accessibility. The manager is looking into making the bedrooms more personal to the people accessing the service. A notice of festival events was seen during a tour of the home in addition to an invite to coffee mornings. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 17 A secure small garden to the rear of the property is accessed from the laundry and the manager reported that service users have been supported with planting shrubs in the garden. Discussions held with staff on duty indicated that the environment on occasions appears to challenge the needs of a couple people due to restricted communal space available, numbers of service users and staff. It was reported that ‘One service user likes the lounge to himself which can cause problems’. The manager reported that the housing association hold responsibility for the repairs of the home and a repairs book was open to inspection. A planned maintenance and renewal programme for the fabric and decoration of the premises has yet to be developed. Domestic staff are employed and discussions with the manager indicated that the staff are assisted with support from employment services when accessing training courses. It was reported that both domestic staff are undertaking an NVQ award. A cleaning schedule is in place and the home was found clean throughout on the day of this unannounced inspection. COSHH products are appropriately stored and the necessary risk assessments and data sheets in place. An infection control policy is in place and the manager stated that she has undertaken a distance-learning course on infection control and all staff are due to access this training through Walsall College shortly. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people accessing this service benefit from a committed and well-trained staff team. EVIDENCE: Although the inspector was not able to directly observe working practices between staff and the people using the service on this occasion, it was evident through discussions held with staff on duty and the manager that the team appear enthusiastic, motivated and committed to their work. Staff on duty had a good understanding of the needs of the service users. Staff spoken with reported that they are provided with very good training opportunities and have accessed a variety of courses in addition to mandatory courses in safe working practices. One member of staff reported that she would like to access training in Makaton, as this would better equip her when supporting people with communication difficulties. The team comprises of sixteen Community Support Staff in addition to three auxiliary staff. The manager reported that three support staff have acquired and NVQ award and two staff are currently undertaking the award. The manager is an NVQ assessor. The home currently has a 26-hour vacancy. The Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 19 criteria for admission is that an individual must be assessed as requiring the minimum of 1:1 support. The manager reported that the main files containing all original documentation and CRB disclosures are held at head office however photocopies of application forms, references are held in the home in a locked filing cabinet which is only accessible by the manager. Two personnel files were randomly selected and contained the necessary documentation and were well presented. Copies of training certificates were also available. Discussions held with the manager indicated that all new staff appointed in September 2005 undertook a ten-day in-house induction in addition to the TOPSS (now Skills for Care) induction. The manager was not aware of the need for staff working in learning disability services to undertake Learning Disability Awards Framework (LDAF) induction programme. A training matrix for 2006/07 for auxiliary staff was available however it was reported that the matrix for support staff was not on site. The manager reported that she is currently developing a training and development plan for the team and the deadline for completion is 30.06.06 this will then be forwarded to the training department. Staff spoken with stated that they had undertaken mandatory training however the manager reported that some staff still require training in moving and handling, lone working and fire safety. Five staff are facilitators for person centred planning (PCP) however PCP’s have yet to be developed. The manager is responsible for providing formal supervision for all staff. She reported that not all supervisions are up to date due to having to undertake thirteen Employee Performance Reviews (EPR) to date. However staff spoken to report that they are in receipt of regular formal supervision and team meetings are held on a regular basis. Evidence of formal supervision meetings were seen on the two personnel files reviewed in addition to signed supervision contracts and EPR’s. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 20 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): 37,39,41 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is effectively managed and promotes the health and safety of service users and staff. EVIDENCE: Ms Ann Watson is the Registered Manager of the home. Ms Watson reported that she has worked for the local authority since 1983 in elderly services and has been in a managerial role for a number of years supporting adults in older people services with complex needs. She is currently undertaking the Registered Managers Award. Ms Watson stated that she holds the DMCS Management Award, D32/33 NVQ Assessor Award, IOSH and has attended numerous courses appropriate to her role. She has identified her own training needs to include learning disability and autism. Ms Watson is line managed by Ms Lorraine Banks, Group Resource Manager based at Oxley Moor House. Ms Watson is contracted to work 37 hours per week and covers a variety of shifts. She reported that she receives regular supervision from her line Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 21 manager and has developed a close working relationship with the manager of Muchall Grove, the service that ten service users transferred from. Staff spoken with reported that the manager is approachable and that overall the home is well managed. The manager reported that a questionnaire has recently been developed in order to gain feedback regarding the service from service users and their relatives and that the questionnaires are due to be distributed shortly. A copy of such was provided to the inspector. The questionnaire is comprehensive and had been developed in a pictorial format. A letter of compliment was seen dated March 2006 which stated ‘The staff at Swan Bank are very friendly and highly professional. I am very pleased with Swan Bank. Thank you very much’. Reports of Regulation 26 visits conducted on 29.04.06 and 31.05.06 were provided to the inspector as requested. The Quality Assurance Reviewing Manager for the local authority undertakes such visits. Both reports state that the home is well run and that during one visit the relaxed, family atmosphere impressed him. Records seen throughout the inspection were presented to a good standard however the manager was advised to condense service users records and achieve records received from another service dated 2003. Health and Safety procedures appeared satisfactory at the time of the inspection. A health and safety policy is available however this was not reviewed on this occasion. The inspector was provided with a copy of a health and safety inspection report of the home undertaken by Unison and the findings satisfactory. Risk assessments for safe working practices are comprehensive and the manager has undertaken training in this area. Service certificates were available and valid, records of fire, drills, emergency lighting, water temperatures, fridge/freezer and cleaning schedules are maintained. It was reported that the majority of staff have undertaken training in safe working practices however without a training matrix available the inspector was unable to validate this. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 22 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 2 2 3 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 2 25 x 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 3 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 3 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 3 3 x Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A – new service 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 2 3 Standard YA1 YA1 YA24 Regulation 4 Schedule 1 5 23 Requirement Room sizes must be included in the homes Statement of Purpose. A Service User Guide must be developed and service users provided with a copy. A planned maintenance and renewal programme for the fabric and decoration of the premises must be developed. A training and development plan must be developed based on the assessed training needs of the team. Timescale for action 01/08/06 01/08/06 01/09/06 4 YA35 18(1)(c) 01/09/06 Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 24 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 2 3 4 5 Refer to Standard YA6 YA19 YA32 YA35 YA42 Good Practice Recommendations It is recommended that person centred plans (PCP’s) be developed and implemented. It is recommended that Health Action Plans be developed and implemented. It is recommended that staff be offered training in Makaton. Staff working in learning disability services should undertake LDAF induction training. It is recommended that staff fully complete mandatory training as soon as possible. Swan Bank DS0000065428.V293076.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Swan Bank DS0000065428.V293076.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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