Inspection on 28/02/06 for The Beeches

This inspection was carried out on 28th February 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Beeches 26/02/10

The Beeches 19/10/07

The Beeches 06/07/06

The Beeches 27/04/05

The Beeches 21/12/04

The Beeches 19/05/04

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 Beeches (The) Fairfield Bungalows Blandford Dorset DT11 7HX Lead Inspector Stephanie Omosevwerha Unannounced Inspection 28th February 2006 09:30 DS0000032198.V283345.R01.S.doc Version 5.1 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 DS0000032198.V283345.R01.S.doc Version 5.1 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. DS0000032198.V283345.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beeches (The) Address Fairfield Bungalows Blandford Dorset DT11 7HX 01258 453436 01258 451540 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) Dorset County Council Susan Joy Tuck Care Home 25 Category(ies) of Learning disability (25) registration, with number of places DS0000032198.V283345.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Staffing levels must be those determined in accordance with guidance recommended by the Department of Health. The home can accommodate one named service user, who has a sensory impairment in the bungalow at The Beeches. The home must meet the staffing levels as agreed in their action plan to the commission dated 12th November 2003. 27th April 2005 Date of last inspection Brief Description of the Service: The Beeches provides accommodation for adults who have a learning disability, providing long-term care and 2 respite beds. The home was purpose built in the 1970’s. Accommodation is arranged over two floors, with the lounges, dining room and domestic kitchen being on the ground floor. There is a large garden to the rear of the property. The home has good access to the local community and is within walking distance of the town centre. The Beeches has a bungalow attached to the main home that currently accommodates three service users. These service users are supported by two members of staff while in the bungalow during the waking day, and one waking night staff. The bungalow has its own kitchen, dining room, lounge and bathroom. The main part of the home is also staffed 24 hours a day. Service users attend local day centres during the weekdays or have day activities arranged by the home. A high level of personal care is provided by staff, with staff supporting residents with bathing, dressing and personal hygiene. DS0000032198.V283345.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over approximately 7 ½ hours. It was the second annual inspection carried out as part of the planned inspection programme for care homes undertaken by CSCI. The inspection also addressed the requirements and recommendation that were made at the previous inspection. The initial part of the inspection was spent with the manager examining records and documentation including service user files, staffing records, and medication records. A tour of the premises was carried out consisting of all communal areas and a sample of residents’ bedrooms. The inspector was able to talk to 3 senior members of staff and then spend time talking with all the residents during their evening meal. Further information held at the CSCI office including previous inspection reports, reports of monthly monitoring visits (R.26) was taken into account when compiling the report. Prior to the inspection comment cards had been received from 3 service users, 13 relatives, 6 health and social care professionals and 3 G.P.s. Analysis of these cards showed that almost all of the respondents were satisfied with the overall service and comments were generally favourable such as “very satisfied and appreciate al the staff do for the residents” and “the staff are clearly a committed group of people who work hard to ensure that their residents are not discriminated against.” One professional felt that whilst “some staff are very good and caring, generally the home feels unwelcoming and is not supportive of the service users.” What the service does well: The manager of the Beeches is well supported by a senior staff team, who have delegated roles and responsibilities that ensures the smooth running of the home. The staff team have worked particularly hard to meet the Care Home Regulations and National Minimum standards demonstrated a strong commitment to improving the service and quality of lives of the residents. To monitor the quality of service the home provides the home have developed an excellent system of quality assurance, which is based on the views of service users surveys that are independently monitored. The home has produced a comprehensive action plan based on this looking at ways to improve things for residents and staff. DS0000032198.V283345.R01.S.doc Version 5.1 Page 6 The home has a committed staff team and a high degree of interaction was observed between residents and members of staff. Residents were treated respectfully and encouraged to make choices in their daily lives by staff who were supportive and caring. There was evidence of good liaison with other professionals ensuring that service users benefited from the specialist support they needed such as psychologists, community nurses and speech and language therapists. Links with family and friend are maintained and visitors are welcomed into the home. All service users have single rooms that are appropriately furnished and personalised to the individuals taste. Service users stated that they enjoyed living in the home, that the staff are nice, that they liked the food and that they had been going out with their keyworkers more often. What has improved since the last inspection? What they could do better: The décor in the home is looking tired in some places and some items of furniture are worn out. For example the bottom of a sofa was torn in the bungalow. Some investment in the environment would give the home a more welcoming and homely feel. The bathing facilities do not currently meet the needs of service users with physical disabilities and appropriate adaptations should be installed. DS0000032198.V283345.R01.S.doc Version 5.1 Page 7 The home’s current medication policy does not cover all aspects of administering medication and this needs to be updated to ensure it reflects current practice in the home. If medication is leaving the home, it is recommended that staff do not sign the MAR sheets but place a code in the appropriate place instead. The home needs to plan towards increasing the number of staff in the home that are qualified to NVQ 2 or equivalent. They are not meeting the current target of having 50 of staff in the home with this qualification. More accurate recording of care staff’s previous qualification would help the home plan more effectively what courses staff need to complete. 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. DS0000032198.V283345.R01.S.doc Version 5.1 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 DS0000032198.V283345.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. The home liaises with professionals and carers to ensure service users needs are assessed fully prior to admission. The homes own assessments have been improved to provide a more detailed picture of service users needs and service users are encouraged to participate in this process. EVIDENCE: There had been no new admissions to the home since the previous inspection when it was recommended that the home’s assessment of service users needs should cover a wider range of needs. The home has a pre-admission assessment that is carried out to ascertain service users needs based on information given by carers. Help lists are also drawn up with service users involvement that are signed to evidence service users agreement with the written account. Care plans have also been revised to include full details of service users needs as set out in Standard 2.2. A sample of 3 service users files was examined as part of this inspection and there was further evidence that community care assessments and care plans had been carried out by care managers prior to service users being admitted to the home. Consultation with other professionals such as psychologists had also been undertaken where necessary. DS0000032198.V283345.R01.S.doc Version 5.1 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, 8 and 9. Improvements to the home’s system of care planning mean these are now much more detailed and well organised giving a comprehensive picture of service users needs. The home demonstrates a commitment to encouraging service users to make decisions and look for ways to increase service users choices and participation in the running of the home. The home has made improvements to the way that risks are managed, which has resulted in service users being able to take responsible risks rather than imposing unnecessary limitations. EVIDENCE: A sample of 3 service users’ files was examined as part of the inspection. These have been organised into a comprehensive record of service users needs. All service users now have a Personal Care Programme that sets out how the home is to meet a whole range of needs. Additional information is also provided in a “Help List” that has been produced in a user friendly format using visual aids to make the information more accessible. This document DS0000032198.V283345.R01.S.doc Version 5.1 Page 11 addresses a variety of needs such as communication, personal care, eating and drinking, toileting, mobility, sleep patterns, health and hobbies. Each service user has an individual service plan that records their goals and outcomes. This document also details service users likes and dislikes and strengths and needs. There was evidence that these documents had been regularly reviewed, including case supervision notes that monitor the ongoing work with service users’ keyworkers. There was evidence that service users were encouraged to make decisions. For example on the day of the inspection, service users were supported to take part in their chosen daytime activity and observation during the evening meal showed service users were asked what they wanted to eat and also chose where they wanted to eat their meal. The home arranges regular Residents Meetings, where service users are given the opportunity to comment on group activities, or raise concerns. The manager has arranged for service users to take part in staff recruitment and staff meetings. It was identified at the last inspection that service users could not access the kitchen for health and safety reasons, as it is an industrial furnished kitchen. Service users can, however, access a further kitchen on the ground floor and service users used this kitchen during the inspection to make cakes and also to cook pancakes after their evening meal. The manager also stated that service users can undertake meal preparation activities in the dining room such as getting their own breakfasts and making their packed lunches. A sample of service users financial records was checked as part of the inspection. These were found to be up-to-date and accurate with receipts kept of all transaction made. 5 residents are wards or court and there money is managed by Dorset County Council. All other residents have their own accounts and are supported to manage their own money. Improvements were noted to the home’s risk management system. Risk assessments were observed on individual service users files and these are now completed on one form and cover a variety of issues. For example managing money, self-medication, personal care and domestic tasks. These forms clearly identified the risk and informed staff what action needed to be taken to prevent them. The inspector particularly noted that risk assessments had been reviewed and used to enable service users to gain new skills such as one service user had now been assessed as able to use a front door key and others were being to supported to use a door key rather than ringing the door bell. DS0000032198.V283345.R01.S.doc Version 5.1 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, 14, 15, 16 and 17. Additional staffing hours have created more choice and flexibility for service users activities and provided more opportunities to access the local community. Service users are supported to maintain contact with their families and friends and visitors are welcomed into the home. The home has explored ways to increase service users responsibilities and promote their independence in the home. Service users have benefited from a more flexible approach to meal times and further opportunities to take part in cooking activities. EVIDENCE: At the last inspection a requirement was made concerning service users accessing the local community and a recommendation made about consulting service users about daytime activities they would like to take part in. Since that inspection, an additional 200 staffing hours per week has been provided. DS0000032198.V283345.R01.S.doc Version 5.1 Page 13 This has enabled service users to have greater choice about their daytime activities and go out into the community on a regular basis. For example on the day of the inspection, two service users went to ‘Monkeyworld’ for the day and another service user went out shopping for the ingredients to make cakes, which was the activity the service user had chosen for that day. The inspector also observed a further group of service users go out to the local supermarket to buy ingredients to make pancakes, which they were going to do that evening. Discussion with service users confirmed they felt they had more choice and were going out much more than previously. There was written evidence that service users had been consulted about their choice of activities in their individual files. Activities were currently being organised over an eight week period and included things such as shopping, room cleaning, cinema trips, going to the hairdressers, cooking, washing, going into town and writing to family. Service users had the opportunity to discuss any additional activities they particularly wanted to do with their keyworker. For example, one resident had recently arranged to go to a music concert. There was a recommendation made at the last inspection that service users should have as part of the basic contract price the option of a seven-day annual holiday outside the home. The manager stated that a variety of holidays were arranged for service users including accessing adult placement or visiting Cornwall and there was some holiday allowance available from the home’s amenity fund. Service users also had an allowance for their accommodation fees whilst on holiday, although they still had to contribute to the cost of their holiday. The home has an open door policy and service users visitors are welcomed into the home. It is usual for ID to be obtained if a visitor is unknown to protect the service users safety. The home has communal areas that can accommodate visits in privacy and service users confirmed they could see their visitors in the home. Family birthdays are recorded on service users files so staff can support service users to send cards and buy presents as appropriate. A requirement was made at the last inspection about service users preparing their own food. The home currently has a large industrial type kitchen that cannot be accessed by service users. The home employs a cook who prepares service users main meals. Whilst the main meals are still prepared for the service users, the home has made progress on providing service users with opportunities to cook and prepare meals. The home has a small domestic kitchen on the ground floor that is now being used by service users. Observation on the day of the inspection showed that one service user made cakes and a further group of service users made pancakes after the evening meal. Service users can choose to eat in the dining room or in the lounges if they prefer, one service user choose to eat in the privacy of his room. DS0000032198.V283345.R01.S.doc Version 5.1 Page 14 The manager told the inspector that there is a fridge in the dining room that service users can access. The breakfast things are put out in the dining room so service users can help themselves, pack lunches are also made by service users in the dining room. DS0000032198.V283345.R01.S.doc Version 5.1 Page 15 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): 19 and 20. Improvements to the recording of service users health records have facilitated the monitoring of service users health promoting their well being. Medication was being managed appropriately in the home, although more comprehensive written guidance for staff would clarify some aspects of administration. EVIDENCE: Service users health needs are recorded on their care plans. There was evidence that service users were supported to maintain a good standard of health and each service user had a health care tracking record that contained details of visits to healthcare professionals such as Doctors, Dentists, Opticians, Chiropodists, OTs and Dieticians. Risk assessments were in place to establish if additional monitoring was needs including issues such as weight loss or breast screening. There was further evidence on service users files of specialist input where necessary e.g. psychologists, community nurses and speech and language therapists. Medicines were stored securely in the home in a locked cupboard. The medication file was examined. The home uses Medicine Administration Records (MAR) charts, which are handwritten. These were found to be up-toDS0000032198.V283345.R01.S.doc Version 5.1 Page 16 date and accurate. The home currently signs when medicines are taken away from the home such as when service users are at day centres. A second member of staff then countersigns this. It was recommended that a code be used instead when medicines are taken away from the home as advised by the pharmacist inspector. All staff who give medication have completed a safe handling of medicines course. The medicines policy was seen and this needs to be updated to ensure all aspects of managing medication are covered, e.g. ordering medicines, receipt of medications, some aspects of administration, providing medicines when a service user is away from the home, verbal changes to medication and when there is a medication error. The home has introduced workbooks for residents to help them work towards self administering their medication. Risk assessments are carried out to ascertain if support is needed and written consent is obtained from service users who are supported with the administration of medication. DS0000032198.V283345.R01.S.doc Version 5.1 Page 17 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): 23. The home has made sure that staff undertake appropriate training in adult protection procedures so they are aware of the correct action to take to safeguard the welfare of service users. EVIDENCE: A requirement was made at the previous inspection due to the fact that on two occasions the home had not followed the appropriate adult protection procedures. There had been no further incidents since this inspection so it was difficult to assess if there had been an improvement. The manager informed the inspector that all staff had now undergone POVA training and felt confident they would be able to follow the correct procedures now. Staff also attend training in managing challenging and aggressive behaviour. It was recommended at the previous inspection that staff receive training in physical intervention or restraint. The manager said that the staff do not currently use any form of physical intervention or restraint in the home. If this became necessary, she said staff would then undertake the appropriate training. DS0000032198.V283345.R01.S.doc Version 5.1 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, 27, 28 and 30. The home provides service users with a safe and comfortable environment; however, some investment is required to improve the standard of décor and furnishings in some parts of the home. Bathing facilities do not currently meet the needs of service users with physical disabilities and appropriate adaptations must be installed. The home is clean and hygienic with satisfactory procedures in place to prevent the spread of infection. EVIDENCE: A tour of the premises was carried out as part of the inspection. All communal areas of the home were seen as well as a sample of 4 service users’ bedrooms. The inspector noted that some of the décor was tired looking and there were signs of wear and tear on some of the furniture. For example, one of the sofas in the bungalow was torn at the bottom. The inspector is aware that there are future development plans for the Beeches, however, in the meantime the environment should be maintained to a reasonable standard and items of worn out furniture replaced. DS0000032198.V283345.R01.S.doc Version 5.1 Page 19 There is a further outstanding requirement to modify the ground floor shower room. The manager confirmed this work has now been approved and will be completed by the timescale, which has now been extended to May 2006. A new cupboard has now been built in one of the lounges to store mobility equipment and aids so these do not impinge on communal areas. The home continues to offer a short term care service despite the fact that the communal areas cannot be separated from the living areas of the permanent residents. A separate laundry room was viewed that is suitable for the needs of service users living in the home. The home has a comprehensive policy in place and guidance for staff on infection control and communicable diseases. Safety equipment is readily available in the home. DS0000032198.V283345.R01.S.doc Version 5.1 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 and 35. The home is now providing additional staffing hours, which means service users have more opportunities and choices in their daily lives. The home now needs to ensure that staff obtain the appropriate qualifications to support them in their work. Improvements have been made to the home’s recruitment procedures to ensure they now comply with the regulations and do not place service users at risk. The home’s training programme has now been expanded to include courses that meet the specialist needs of service users living in the home as well as their basic care needs. EVIDENCE: Examination of rotas showed that there had been an increase of 200 staffing hours per week. This meant that 4 care staff work throughout the day supporting service users with their chosen daytime activities (this will increase to 5 staff from the 20/03/06). The home has 29 care staff positions and 5 are vacant at present. The vacant gaps in the rota are currently being filled by existing care staff or a team of regular relief staff, which means the home is not using any agency staff at present. There are seven staff on shift in the evenings between and in the mornings. DS0000032198.V283345.R01.S.doc Version 5.1 Page 21 Observation during the inspection showed that staff worked closely with service users. There were sufficient staff on duty to support service users with their chose of activity. For example during the evening a small group of residents were able to go out to the local supermarket to purchase the ingredients for the pancakes they wished to make. The home is not currently achieving the target of having 50 of care staff achieving a NVQ2 in care, although it was not clear if any staff had achieved this in the previous employment. The manager stated that 2 members of staff had commenced the NVQ2 in September 2005. It is recommended that staff’s previous qualifications are recorded so the home can effectively plan towards the 50 target they need to meet. A sample of 2 staff records was checked as part of the inspection as there had been a breach in regulations at the previous inspection. Records now showed that appropriate checks were being carried out. For example a new member of staff had a POVA first check in place and a risk assessment had been carried out with a named person on the rota identified to carry out supervision of the workers duties until a full CRB check had been returned. The training plan was observed and the inspector noted that staff had now undertaken courses in Autism in December 2005 and Visual Impairment in January 2006. The manager said core training includes induction training, POVA and the LDAF induction and foundation courses that all staff are now carrying out. DS0000032198.V283345.R01.S.doc Version 5.1 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 and 41. The manager is well supported by her senior team whose roles and responsibilities are clearly defined, which ensures the smooth running of the home. A significant improvement to the way information is organised has meant records are now much clearer and easier for staff to access. The home has developed an excellent system for reviewing their performance based on service users views to set objectives and action points to improve the quality of service over the forthcoming year. EVIDENCE: The registered manager, Susan Tuck, has a substantial amount of experience in working and managing services for adults with learning disabilities. She has achieved her NVQ 4 Registered Managers Award and also has a Diploma in Care. She is supported in her role by a team of Senior Care Officers who all have delegated responsibilities that ensures the smooth running of the home. DS0000032198.V283345.R01.S.doc Version 5.1 Page 23 The home has worked hard to improve their systems of recording. Information that was old has been archived and service users files have been reorganised to ensure they are much clearer for members of staff to follow. All information required by regulation is present in service users care files. The home has developed an excellent quality assurance framework, which sets out the homes objectives for the forthcoming year based on the outcome of questionnaires that have been sent to service users, staff and carers. The questionnaires are analysed independently by the Performance Review Team at County Hall and the results sent back to the home. A report is then compiled setting out the objectives, action points and outcomes for residents; staff; short term care; carers, family and friends; catering; compliments and complaints; national minimum standards; diversity. DS0000032198.V283345.R01.S.doc Version 5.1 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 1 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 X 3 X 4 X 3 X X DS0000032198.V283345.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 Requirement The registered provider needs to up-date the medicines policy to ensure it covers all aspects of the administration of medication and it accurately reflects current practice in the home. Action must be taken to modify the ground floor shower to enable service users to be as independent as possible when using it. (Previous timescale of 30/08/04 not met.) The registered provider needs to achieve the target of at least 50 of care staff achieving a NVQ 2 qualification in care. (Previous timescale of 01/09/05 not met.) Timescale for action 30/06/06 2. YA27 23 31/05/06 3. YA32 18 30/06/06 DS0000032198.V283345.R01.S.doc Version 5.1 Page 26 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 YA14 YA20 YA24 YA28 YA32 Good Practice Recommendations Service users should have as part of the basic contract price the option of a seven day annual holiday outside the home. It is recommended that a code be used instead of a signature when medicines are taken away from the home, e.g. when a service user is attending a day centre. It is recommended that consideration be given to redecorating some areas of the home and replacing items of worn furniture. It is recommended that the home’s short term care service be reviewed, as the communal areas cannot be separated from the living areas of the permanent residents. It is recommended that staff’s previous qualifications are recorded so the home can effectively plan towards the 50 target of qualified staff that they need to meet. DS0000032198.V283345.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000032198.V283345.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!