CARE HOME ADULTS 18-65
The Bungalow 115 Cross Keys Lane Hadley Telford Shropshire TF1 5LR Lead Inspector
Rebecca Harrison Key Unannounced Inspection 10th July 2006 09:05 The Bungalow DS0000064999.V296534.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 The Bungalow DS0000064999.V296534.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. The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Bungalow Address 115 Cross Keys Lane Hadley Telford Shropshire TF1 5LR 01952 260712 01952 610996 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) Care Tech Community Services Limited Mrs Claire Goodwin Care Home 3 Category(ies) of Learning disability (3) registration, with number of places The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5th December 2005 Brief Description of the Service: The Bungalow is registered with the Commission for Social Care Inspection to provide accommodation and personal care for a maximum of three adults who have a learning disability. The home is situated in Hadley, Telford and is accessible to local amenities, local transport and relevant support services. The home is in keeping with the local community. CareTech Community Services Ltd is the provider and was registered with CSCI on 11.08.05. The responsible individual is Mr Stewart Wallace and the registered manager is Ms Claire Goodwin. Caretech’s philosophy is included in the Statement of Purpose for the home and states ‘CareTech and their staff work on the philosophy of enabling people to live as full a life as possible, supporting them in their daily activities and any identified long term plans. We recognise that all people with disabilities should be given due respect to their individuality enabling all to be fully involved in any decisions having an affect on their lifestyle commensurate to the level of their abilities and enabling people to maintain all their entitlement associated with citizenship’ The current fees charged per person range from £1350.00 to £1608.08 per week. The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection started at 09.05 a.m. and lasted five hours. It was carried out by talking with both service users, the manager and the staff on duty, case tracking, observing work practices, reviewing a number of records and a full tour of the home. 22 key National Minimum Standards for younger adults were assessed in addition to Standard 5 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 service users, manager and staff on duty were welcoming and co-operated fully throughout the inspection. The purpose of this unannounced inspection was to review the progress made since the last inspection undertaken on 5th December 2005. Two requirements and one recommendation were made as a result of the inspection. No complaints have been received by the home or referred to the Commission for Social Care Inspection (CSCI) since the last inspection and there have been no referrals made adult protection procedures. What the service does well:
Care documentation is comprehensive and details the individual assessed needs of the service users and includes clear preferences and guidance on their support requirements. Both service users have been formally reviewed since the last inspection and records evidence that the service user and significant others attended the reviews. Review documentation includes agreed needs, desired outcomes and proposed actions. Family links are well established and promoted. One of the service users was recently supported to attend a relatives wedding and it was evident through speaking with her that she very much enjoyed the occasion. Questionnaires have recently been sent to relatives and other significant people and the response received from the relatives of one service user were very positive and stated ‘We feel very lucky that X is living in such a happy and relaxed atmosphere’. Staff are provided with good training opportunities, they function well as a team and through adopting a positive and consistent approach the behaviours previously displayed by one individual have significantly reduced. Procedures for the management of health and safety are satisfactory and the recruitment of staff robust.
The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 6 Staff reported that the team promotes service users independence, their individuality, dignity and wellbeing and provide opportunities that enable service users to make informed choices about their own lives. What has improved since the last inspection? What they could do better:
The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 7 Service users are very much looking forward to the redevelopment of their home and should benefit from living in an environment more appropriate to their lifestyle. Such work needs to be undertaken as soon as positive to improve the current living environment. Person Centred Plans should to be developed and implemented with both service users as soon as possible. Upon receipt of the views of service users, relatives and significant others, the results of surveys should be published and made available on how the home is achieving goals for the people accommodated. Feedback received from staff and managers indicate maintenance response times could be improved. One staff member reported information technology equipment would benefit the service and provide greater communication across the organisation. The manager and staff on duty expressed concerns in relation to the current physical intervention training used. It was reported that some techniques are inappropriate and do not fully protect the dignity of service users, particularly if used in a community setting. Individual staff training profiles should be developed as soon as possible. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 to successfully accommodate an admission to the home. EVIDENCE: There have been no new admissions to the home since the last inspection. The last person to be admitted to the home was on 29th November 2005. The homes procedure for admission was found to be satisfactory when assessed at the inspection undertaken on 5th December 2005. Discussions held with service users, manager and staff on duty evidence that the placement has proved successful and compatibility good. The home currently has one vacancy however there are no plans to admit a further person until major refurbishment of the home has been undertaken. The person most recently admitted reported that he likes living at his new home. Signed contracts between the organisation and service user were seen on both service users files. The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. 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 the two people currently living at the home was reviewed at length. Support requirements seen on each file detailed the individual assessed needs of the service users and included clear preferences and guidance. The care documentation on both files was comprehensive. A new member of staff on duty confirmed that he was provided with sufficient information to appropriately support the two people accommodated. A Person Centred Plan (PCP) was seen on one file completed under the previous registered provider. The manager, who is a PCP facilitator, reported that the organisation is looking to develop and implement PCP’s shortly. The manager
The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 11 committed to ensuring a photograph of one service user is placed on file as soon as possible. Records seen on file evidence that the person admitted to the home in November was formally reviewed on 11.01.06 and 14.06.06. The service user and significant others attended both reviews. Review documentation was detailed and included agreed needs, desired outcomes and proposed actions. It was reported that neither of the service users currently have an ‘active’ advocate by choice however this would be facilitated if required. Discussions held with both service users evidence that both individuals are able to make informed choices and they are also provided with an allocated key worker who they meet with regularly for ‘Talk Time’. The outcome of meetings was seen recorded on both files reviewed. The organisation has recently introduced a service user forum whereby one service user from each home meets with other representatives from homes across Shropshire and Birmingham. The first meeting took place on 18.05.06 and the person most recently admitted to the home represented the service supported by designated staff member. The staff member stated that the forum proved very successful and actively promotes decision-making processes across the organisation and provides an opportunity for service users to meet up. Discussions held with a service user and managers indicate that the behaviours of one individual have significantly reduced and the team are successfully supporting her to manage her behaviours positively. CSCI were notified under Regulation 37 of two incidents that have occurred since the last inspection and appropriate action was taken by the home. Risk assessments seen on both of the service user files were comprehensive with evidence that people are enabled to take responsible risks, which are regularly reviewed. Generic risk assessments have been developed by the organisation in addition to comprehensive individualised assessments completed by the staff team. The manager reported that staff are trained in risk management. The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with good opportunities for community presence and participation. Family links are maintained, rights and responsibilities promoted and people provided with a varied and balanced diet. EVIDENCE: Since the last inspection both service users have expressed an interest in accessing college courses from September. An appointment with a Community Learning Worker was made for one individual at the local library and access to courses appropriate to the individual were discussed. The other service user has also visited the local college and sought information on courses of interest and is hoping to commence in the new term. Weekly activities are recorded on activity sheets in addition to each individual having a ‘Life and Leisure Experiences Plan’ in place which is developed with the support of allocated key workers. On arrival at the home one service user was preparing to attend her voluntary job based at Laburnums. She reported that she assists the cook with cooking and making drinks and very much enjoys her work. It was
The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 13 reported that she has undertaken training in food hygiene and has good cookery skills. The service user most recently admitted to the service has been supported with a garden project and a garden file with information and photographs of visits to garden centres has been developed with him and this was shared with the inspector. During the inspection he was supported to visit a sister home to meet with a service user and staff to discuss arrangements to visit Cadburys World. He also informed the inspector of his recent day out which included swimming and a trip on a coach. He regularly chooses to attend the local church and has developed positive friendships within his community. Preferences in relation to routines, religious observance and the promotion of community links and social inclusion were available on both service user files reviewed in addition to contact sheets detailing all contact made with family and significant others. Discussions held with both service users and staff and records seen evidence that links with families are established and promoted. One of the service users was very recently supported to attend a relatives wedding and it was evident that she very much enjoyed the occasion. Both people are provided with a key to their bedroom and use this facility. Responsibilities for housekeeping tasks were discussed with both service users during the inspection and these are also found recorded on both of the service user files, supported by the necessary risk assessments. Discussions held with service users evidence that they play an active role in menu planning and meal preparation and spoke about taking it in turns to plan forthcoming meals and are supported with food shopping. Menus seen were varied and appeared balanced taking into account individual preferences. Both service users reported that they like the food provided and also enjoy having meals out. The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health care needs are closely monitored with evidence of regular review with healthcare professionals. Personal support is provided according to individual assessed needs. The home has a satisfactory system of handling, storing and managing medication. EVIDENCE: Health Action Plans were available on both service user files. Health documentation seen was detailed with evidence that people’s health is monitored and regularly reviewed with relevant health professionals. Records seen on files evidence that individuals are supported to access NHS Healthcare facilities and all appointments and outcomes recorded. Where an individual has declined to attend an outpatients appointment for health screening purposes this was also clearly recorded. Preferences in relation to personal support were clearly documented on both of the service user files. Key workers are provided to ensure consistency and continuity of support. The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 15 Medication procedures appeared satisfactory at the time of the inspection. Prescribed medication is supplied by Boots Chemists in the form of the Monitored Dosage System (MDS). The manager stated that all staff have received training in this system and are currently undertaking the ‘Aset’ Certificate in Managing and Safe Handling of Medicines distance learning course run by Walford College. Since the last inspection one service user requested to withdraw from prescribed medication and it was reported that the Associate Specialist from the local learning disability team and the staff supported this decision. It was evident through discussions held with the service user that she is very happy with this decision and is doing well. Controlled drugs are currently not prescribed however the home has appropriate storage facility available. The homes policy on medication was not reviewed on this occasion. The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure in place and procedures to safeguard service users from potential abuse. EVIDENCE: A complaints procedure is in place. No complaints were seen recorded in the complain log and the manager confirmed that there have been no complaints received since the last inspection. No formal complaints have been referred to the Commission for Social Care Inspection and there have been no referrals made under adult protection procedures. A complaints pack has been distributed to each service user and these were seen on the working files. A new staff member reported that he has received training in Adult Protection and Physical Intervention. The manager and staff on duty expressed concerns in relation to the current physical intervention training used. It was reported that some techniques are inappropriate and do not fully protect the dignity of service users, particularly if used in a community setting. The finances of the two people case tracked were checked by the inspector with the manager and were an accurate reflection of the records held. Service users are provided with their own bank account and are supported with the management of their finances. Records and finances are checked at staff handover. It was reported that training in adult protection has been booked for staff that have yet to attend.
The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premise is to be fully refurbished and extended to provide service users with more suitable and homely place to live. EVIDENCE: The home is conveniently located in a residential area of Hadley, Telford, close to local amenities and just a short journey from Wellington and Telford Town Centre. The organisation has liaised with CSCI in relation to undertaking a major refurbishment of the home and planning permission has been sought. Following the refurbishment the organisation wish to apply to vary their registration to accommodate four people. The manager reported that she is undertaking a risk assessment of building works and plans are in place to support service users when the works are scheduled. A full environmental tour of the home was undertaken and service users were happy to show the inspector their bedrooms and living space. Discussions held with service users evidence that they are both very much looking forward to the complete refurbishment of their home. Although the home appears ‘dated’
The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 18 it is comfortable and was found clean and tidy throughout. The back garden is overgrown and this was immediately actioned by the manager who had just returned from two weeks annual leave. The hedges to the front drive are overgrown and in need of tidying up. Both service users are responsible for assisting with household tasks. On arrival to the home a service user was being supported to attend to his laundry and was later seen pegging out his washing on the line and hovering the ground floor. The other service user informed the inspector that she cleans her room on a daily basis and that jobs are shared between them. Service users are involved in purchasing and using COSHH products supported by a risk assessment and relevant data sheets. Discussions held with a new staff member and a certificate seen on his personnel file evidence that he has undertaken training in Infection Control. The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a well-trained, committed and motivated staff team and are safeguarded by the homes robust recruitment procedures. EVIDENCE: Observations made throughout the inspection and discussions held with staff on duty evidence that staff are committed to their roles and responsibilities and function well as a team to support the two people accommodated at the home. Staff were seen to interact with service users in an appropriate manner and have a clear understanding of the needs of the individuals they support. Both service users stated that the staff are good and it is evident through discussions held and observations made that staff have developed positive working relationships with the two people whom they support. Behaviours displayed by one individual have significantly reduced with the support of clear guidelines available to ensure staff are consistent in their approach. The home employs a manager, two part-time deputies and four support staff. Three staff have obtained an NVQ award and one staff member is currently undertaking the award. A new staff member spoken with reported that staff morale is very good and the team functions well and is supportive of one another. He remarked that the
The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 20 organisation appear a very good employer and provide good policies and procedures and opportunities for training. Since the last inspection one support staff was appointed on 08.02.06 and a further support worker has very recently been appointed and is awaiting PoVA checks and a CRB disclosure before commencing work. The personnel file for the person appointed in February was found well presented and contained the relevant documentation required in addition to evidence of regular formal supervision and training certificates. CSCI have agreed for the organisation to hold CRB disclosures at the head office. A CRB Tracker form is held in the home and this was seen on file. The manager reported that one service user played an active role in the interview process of staff recruited for the home. Discussions held with the staff member employed in February evidence that he has completed the LDAF induction training and is nearing completion of the foundation training. He reported that he has received mandatory training in safe working practices in addition to training in adult protection, infection control, physical intervention and has been assessed in the administration of medication. It was reported that all staff are currently undertaking the Aset accredited medication training. A training file is in place and a general matrix of mandatory training for home based staff was available. The manager confirmed that staff requiring mandatory training have been booked to attend training as soon as possible. A Training Plan for 2006 was seen and the manager has identified training for her team to include Equal opportunities and diversity, adult protection, NVCIphysical intervention, dementia, communication, age concern and infection control. Individual training profiles have yet to be developed. The manager reported that she has not yet undertaken formal appraisals with her staff however on completion of these further courses identified will be included on the plan and forwarded to the training department. The manager is currently undertaking a SWOT (strengths, weaknesses, opportunities and threats) analysis of her team. The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made 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. The organisation reviews the homes aspects of performance and ensures the premises are managed and maintained in a safe manner. EVIDENCE: The manager of the home is Ms Claire Goodwin, whose registration was approved by CSCI on 24th May 2006. She is contracted to work 40 hours per week and is currently working towards the NVQ level 4 and Registered Managers Award. She reported that since the last inspection she has undertaken training in safe working practices, policies and procedures, Induction for trainee managers, for which she is currently a mentor to a deputy. She is currently undertaking accredited medication training and is also a member of the organisations health and safety committee. Ms Goodwin is
The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 22 line managed by Ms Anne Morrison, Area Manager. A new member of staff stated ‘Claire’s a fantastic manager who is very dedicated to the service users, supportive, open and approachable and welcomes new ideas from her team’. A requirement was made as a result of the last inspection for the views of service users; family, stakeholders etc must be sought on how the home is achieving goals for service users. Questionnaires have recently been sent to relatives and other significant people and the response received from the relatives of a service user were very positive and stated that the conduct of the staff team is ‘excellent’ and that they are made very welcome when they visit and that the strengths of the service is the ‘individual caring, sympathetic understanding of X needs’. They also commented that ‘We feel very lucky that X is living in such a happy and relaxed atmosphere’. The service users have recently been provided with questionnaires and the manager committed to compiling a report based on the outcomes of all the views received. A Quality Assurance Audit was undertaken on 14.12.05 and the home scored 80 . A further audit of the home was undertaken on 13.03.06 and a score of 86 was achieved. Both reports were comprehensive and generally positive with recommendations being made and the manager is working towards addressing these. Monthly visits required under Regulation 26 are undertaken by the organisation and a report forwarded to the local CSCI office. An Annual Development Plan has been produced as required by the previous inspection. Health and Safety procedures appeared satisfactory at the time of the inspection with the exception of the bath water temperature when tested by the inspector reached 48°C. This was immediately actioned by the manager and reported to maintenance. A health and safety policy is available however this was not reviewed on this occasion. The home has weekly and monthly checklists in place and records evidence the last monthly audit of the home was undertaken on 03.07.06. Relevant service certificates were available and valid in addition to checks at the required frequencies on fire, emergency lighting, hot water temperatures, food and fridge/freezer checks and cleaning schedules completed. Risk assessments for safe working practices are comprehensive. A training matrix for mandatory training is in place. As previously stated the manager is a member of the health and Safety committee for the organisation. The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 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 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x The Bungalow DS0000064999.V296534.R01.S.doc Version 5.2 Page 24 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 YA35 Regulation 18(1) (c) Requirement Each staff member must have an individual training profile. Timescale for action 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard YA6 YA24 YA24 Good Practice Recommendations It is recommended that a person centred plan be developed with both individuals as soon as possible. It is recommended that the home continue to liaise with CSCI regarding the refurbishment of the home. It is recommended that the garden and hedges are attended to as soon as possible. The Bungalow DS0000064999.V296534.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
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