Inspection on 27/09/06 for The Minster

This inspection was carried out on 27th September 2006.

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

The inspector found 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Minster 22/08/07

The Minster 13/02/06

The Minster 03/08/05

The Minster 09/03/05

The Minster 26/07/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 The Minster Mill Street North Petherton Bridgwater Somerset TA6 6LX Lead Inspector Loli Ruiz Unannounced Inspection 27th September 2006 10:00 The Minster DS0000059630.V312473.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 Minster DS0000059630.V312473.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 Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Minster Address Mill Street North Petherton Bridgwater Somerset TA6 6LX 01278 661528 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) Voyage Ltd Nicola Rossenrode Care Home 10 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 10 persons in categories LD and PD. Date of last inspection 13/02/2006 Brief Description of the Service: The Minster is registered with the Commission for Social Care Inspection to accommodate ten service users with a learning disability and associated physical needs. Voyage owns the home. The home is situated in the village of North Petherton, near Bridgwater. The home can accommodate service users who require a bedroom on the ground floor. However, the home does not have a passenger lift to the first floor. All bedrooms are of single occupancy and have full en-suite facilities. It is decorated and furnished to a very high standard with an extensive rear garden and patio areas. The Minster is situated in the heart of the village and is very close to all community resources such as shops, post office, church, pubs, chemist, doctors surgery, library and hairdressers. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted over one day. The registered manager is absent from the home at present and Mrs Sam Law, has been appointed acting manager. Mrs Law was in the home and assisted throughout the inspection. The Inspector would like to thank the service users, Mrs Law and the staff team for making the inspector welcome at the home and for their contribution to the inspection process. At the time of the Inspection ten service users were living at the home. One of these was in hospital. The Inspector viewed most parts of the home with Mrs Law; viewed records in relation to care and support plans, health and safety and medicines records. The Inspector met all but one of the service users. The inspector also met the staff on duty during the two shifts and privately spoke with four of them. The Inspector observed that the staff team continues to interact with service users in a very professional, caring and supportive manner. What the service does well: Good practice detailed in the last inspection report had continued. The Minster provides a very high standard of accommodation and facilities. All parts of the home are accessible to the service users who have no mobility difficulties and there are ramped areas for service users who have the use of wheelchairs to enable full access of all ground floors and outside facilities. The home has aids and adaptations to promote the independence of the service users. There are detailed care and support plans with risk assessments where needed. All records were well maintained. Service users access a variety of health care professionals as and when needed. The home maintains good records in relation to health and safety. The team wish to provide service users with a variety of opportunities, experiences, choice, independence and involvement as much as possible. The home conducts regular service user meetings. Service users are provided with good opportunities for social interaction and positively enabled to maintain contact with relatives and important others. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 6 Service users knew who their key worker was and provided positive feedback about living at The Minster. The staff team appeared well motivated, liked their work, indicated that they were well supported and that they valued their team. There was evidence of good staff induction procedures that included LDAF training. A representative of Voyage visits the home at least monthly to audit and support the service. Copies of areas reviewed during these visits are forwarded to CSCI. What has improved since the last inspection? What they could do better: There must be evidence that a comprehensive assessment of needs has been carried out at the time of considering a new admission. The involvement of the service user concerned and (or) their main carer in this process must be evidenced by including their signature and transition work done, documented. The home should ensure that care plans are also signed and dated by the service user, Registered Manager, or other interested stakeholders if appropriate, to clarify the agreement of the plan of care and support to each service user. This recommendation from the last inspection is restated. Detailed records should be kept of service users bank details that link with daily expenditure and demonstrate the breakdown of individual outgoing and personal allowances. A recommendation from the last inspection is restated. The flooring in the shower room should be replaced as the areas now unstuck and with air bubbles are likely to deteriorate and become unsafe. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 7 Staff statutory training and updates must be provided when due. The work in progress to increase the number of staff qualified to NVQ level should be given new impetus so that the minimum standard of 50 is achieved soon. 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 Minster DS0000059630.V312473.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 Minster DS0000059630.V312473.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): 1, 2, 3 The quality in this outcome group is adequate. Care records do not evidence that a robust admissions procedure is in place. EVIDENCE: The Home has a Statement of Purpose and Service user Guide. These are available for prospective service users, their relatives and placing authorities. Three care records were selected for inspection from the latest admissions to the home. Two of the service users chosen had been in the home since the end of 2005 but there was a new service user admitted since. The file of this person was still at head office and not available for inspection. The two other files had evidence of pre-admission assessments undertaken by the home. These were not a comprehensive account of the person’s needs. They had not been signed by the service users or relative to show agreement. Looking for other professional assessments, the ones found from the referring local authority were from previous years and not contemporaneous with the admission. There was no indication in these files of they transition work that staff evidenced they always do. Speaking with two of the service users concerned, it was clear that the home was meeting their needs and they were settled and happy living in the home. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 10 The exit door alarms were disconnected at the time of the last inspection and the garden gate mended. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 11 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, 7,8,9, The quality in this outcome group was good. There are detailed care and support plans with risk assessments where needed. The plans had been appropriately reviewed, however the service users signatures were not included in care plans or review records seen. Service users are involved with deciding all aspects of daily living and receive the support they need to make decisions to help them develop. Risk taking is part of daily living and the staff team take steps to minimise unnecessary hazards. EVIDENCE: There were good plans of care and support in the records seen. These were not signed by the service users or their advocates to show their involvement. Key workers continue to conduct monthly reviews with summaries kept. There was evidence of timely care plan reviews, however the service user involvement should be made explicit by including their signature or sign. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 12 The inspector discussed in some detail practices regarding physical intervention and was satisfied that the practice, as explained by staff, corresponded well with the Behaviour Management Guidelines evident in the care files. Risk Assessments have been reviewed and updated as needed. Good guidelines and information sheets were included in each file to assist in the event of unexplained absences. While exit doors were locked there was evidence of freedom of movement within the home and the garden. Continuous staff support was evident to enable service users to access outdoor events, as agreed with them in their daily activity plans. The previous inspection recommended that a clear record be maintained of bank accounts linking with the daily expenditure records. While daily transactions were well documented, appropriately signed, included receipts and documented evidence of cash taken out, there was no indication of the banks or PO accounts that each person had. Mrs Law agreed that statements should be put altogether to clearly document the links between the different records. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 13 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): 11, 12, 13, 14, 15, 16, 17 The quality in this outcome group was good. The home encourages and supports service users to access the local community and to partake in a variety of educational, leisure, recreational and social activities. The home encourages and enables contact with family and friends. Service users are treated with respect and assisted with carrying out responsibilities. Staff assist service users with planning a well balanced and healthy set of menus. EVIDENCE: Six of the 9 service users were out during the day taking part in the planned activities of the day as agreed with them. A small group had gone to an arts The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 14 session, one had gone shopping and another locally to collect own scripts. In the afternoon some service users were attending the gym and others were provided with personal alternative therapy sessions in-house by a qualified therapist. Service users were observed engaged in games with staff and being encouraged to undertake agreed duties such as helping with tidying up after the main meal. Activities are based on individual choice/need and records are kept of all activities that are undertaken. One of the service users explained how enjoyable were “1:1” sessions with the key worker “ time just for me”. College timetables were included in care records seen. A staff member gave evidence of efforts made to find a venue for existing interests such as piano lessons. Service users have been provided with day trips out but so far no annual holiday during 2006. Mrs Law has planned holidays for all in small groups and various venues and some of these have already been booked. Service users indicated that they were looking forward to their holiday. Service users and records seen evidenced frequent contact with relatives. Some service users go to the parental home regularly. Service users private space was clearly personalised and they access it freely, as well as communal areas of the home. A key was fitted and issued for one service user and Mrs Law would fit other locks on demand. Service users were encouraged to respect the private spaces of others. A service user indicated a good understanding of “my rights” and attended self-advocacy meetings. Service users are involved in menu planning. Menus are adapted to suit individual need and wishes. On the day one person took a soft diet and another a reducing diet. One person had beans instead of peas on request. The Inspector looked at the store cupboard and the kitchen. It was pleasing to see a good supply of fresh vegetables and fruits and branded products on the shelves. Lunch time was relaxed and unhurried. The meal was wholesome, appetising and served in good portions. Service users took active part in carrying their meals and clearing after themselves. As in the previous inspection there was a lack of ordinary frills, i.e. placemats, side plates, napkins and condiments, were not used or offered, giving the meal time an institutionalised feel that spoiled overall good catering practices in the home. Mrs Law agreed that there was no reason for this omission and agreed to review this. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 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): 18,19,20, 21 The quality in this outcome group was adequate. Service users benefit from flexible support, staff who understand their individual needs and the necessary equipment to maximise independence. Service users have good access to a variety of to healthcare professionals with records kept. The home maintains good records of the storage, administration and disposal of medicines, however there are shortfalls in the medicines training of staff. The home’s staff members support Service users when they need hospitalisation. EVIDENCE: There was evidence during the inspection of staff understanding the individual needs of service users and acting to protect them. Some had a need for space, another a need to rest following an illness months ago. Staff explained to a service user the need of another to be unmolested at a particular time and helped by engaging the person otherwise. Two service users have wheelchairs. One of them is wheelchair independent indoors. A service user has padded bedsides for their protection. A listening The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 16 device had been installed in this room for use at night for the same safety reasons. The home has adapted vehicles and there are always trained drivers on duty. Up to date risk assessments were in place for all adaptations and practices. There were also records of safety checks of mobile equipment. Mrs Law agreed to ask the Occupational Therapist to review the safety of the pads used on bedsides for one person. Access to all health care professionals were well documented in the care records seen. These included visits to the GP and Consultant Psychiatrist, chiropodist, optician and dentist. There were records of health monitoring such as weight records and dietary input. Medication records were well maintained. Mrs Law had recently incorporated in the Medication Administration Charts the recording of over-the counter medicines that service users used, and asked the GP and pharmacist to print these on the charts. Service users were not thought able to keep their own medication. This should be reviewed as new service users come to the home with differing abilities. The medicines cupboard is upstairs and blister packs and other medicines are carried to the dining room in a tools box. Mrs Law planned to provide storage downstairs and during the inspection suitable lockable cupboards were identified that could be used for that purpose. There is storage provision for controlled drugs although these were not in use at the time. Medication is administered by senior staff and night staff have also access to the “as required” cupboard. All staff had received rectal Diazepam training. Looking at the training matrix, it was obvious that not all senior staff had received medication training and others had not had the necessary updates as they must have. A requirement was made. The staff team was at the time supporting a service user in a Bristol hospital and taking turns with relatives to stay with the person over the 24 hours period. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 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): 22, 23 The quality in this outcome group was good. The home has a detailed complaints procedure and there are policies and procedures in place to safeguard vulnerable service users. EVIDENCE: The home has a complaints policy. A record is kept of complaints that are received at the home. One complaint relating to an outdoor environmental issue had been received since the last inspection. It had been recorded appropriately and was being acted upon by the company. There is a copy of the Safeguarding Vulnerable Adults procedure. The home has in the past taken appropriate steps in relation to the safeguarding of vulnerable adults and has kept the Commission for Social Care Inspection informed. Staff spoken with were aware of POVA issues and senior staff knew how to support staff in connection with the whistle blowing policy. All prospective staff has a POVA check and an Enhanced CRB clearance before being employed to work at the home. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 The quality in this outcome group was adequate. The Minster is fully accessible and designed to meet the needs of the service users. Service users have private bedrooms that are fully personalised, well furnished, spacious and have their own possessions and equipment around them. All rooms have en-suite bath/shower rooms with additional communal WCs a bathroom and a shower-room. On the day of the inspection the home was generally clean and tidy but one room had an unacceptable odour. EVIDENCE: The majority of areas of the home were viewed in the company of Mrs Law. Communal areas were spacious, well furnished, decorated and homely. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 19 All ground floor areas of the home are wheelchair accessible, including accessible pathways around the exterior of the home. There is a large patio area to the rear of the property that has access to the large, well-maintained rear garden. Aids and adaptations are provided to meet individual need. The shared bathroom and toilet facilities are spacious and well equipped. There are plans to provide a bath in every en-suite where one or two bedrooms have walk-in showers, and possibly to extend one of the en-suites. A new washing machine was due to be installed in the laundry room. The home was generally maintained in a clean and tidy condition with the exception of corridors that were dusty and in need of vacuuming and of a private WC that had an unacceptable odour. A requirement was made. Materials and equipment for the control of spread of infection was available in all necessary areas and it was observed that staff wore protective clothing when dealing with food. The kitchen was maintained in a clean and hygienic condition. Cleaning schedules were observed and food safety notices displayed. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 The quality in this outcome group was adequate. A competent and effective staff team supports service users. Staff members have delegated areas of responsibilities and are clear about each other’s roles. Staff numbers trained at NVQ are below the 50 minimum. All staff receive LADAF training. Service users are protected by the recruitment practices of the home with good induction arrangements and a well supervised staff team. Adequate staffing numbers have been maintained. EVIDENCE: The inspector spent over 6 hours in the home and took the midday meal with service users. Throughout the day staff were observed supporting service users mindful of their wishes and each person’s specific needs. The acting manager had only been in the home one week, yet the team worked effectively and the days tasks were accomplished without fuss. There was a relaxed and positive atmosphere in the home. There were enough staff on duty to provide the planned activities and the supervision and support needed by each individual. Staff members took it in turn to support the person hospitalised in Bristol and this had put additional The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 21 stresses on the team, however staff confirmed that they were managing to cover absences, although this meant sometimes working many extra hours. Staff and service users spoken with confirmed to relationships of mutual regard. Service users indicated that they were happy in the home and happy with the life style provided. A number of staff members are working towards NVQ qualifications and others are registered to do it. While the percentage of NVQ trained staff is as yet very low, it is expected that this will be changing within the next few months as Mrs Law aims to achieve NVQ 2 for support staff and NVQ 3 for supervisory staff. Staff and records confirmed that they all receive LDAF training on induction and at subsequent levels. Mrs Law is also planning to access Total Communication (TC) training for staff as at present only a few staff have had TC training. The files of the newest staff were inspected and contained proof of appropriate vetting procedures: CRB, POVA, references, ID and address checks performed. Files also evidenced good induction practices. Files and staff evidenced that they receive regular formal supervision and staff spoke highly of the acting manager, whom they considered approachable and supportive. Staff training needs are identified during supervision and training for them is requested from the company. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42 The quality in this outcome group was good. Service users benefit from the leadership and management style of the new acting manager. The staff team continues to seek the views of the service users, works in cooperation with relatives and advocates and Voyage has good systems for monitoring the quality of the services provided. Records inspected were well organised and securely stored. The home works to comply with all health and safety requirements, however significant gaps in health and safety training could jeopardise the safety of service users and staff. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager was absent from the home at the time of the inspection. Mrs Sam Law, acting manager had been in post just a week but already had won the trust of staff and introduced improvements. Mrs Law has performed a deputy manager’s role for sometime in other Voyage homes. She has a friendly and approachable management style that was appreciated by staff members. Mrs Law has NVQ III, is a Total Communication coordinator and has registered to do the Registered Managers Award. Mrs Law is supported by the company’s Operations Manager who carries out monthly visits and plans with Mrs Law improvements identified in their annual plan for the home. Copies of the contents of monthly visits are forwarded to CSCI. Staff indicated that service users meetings are regularly arranged. Records of these meetings were not inspected but the previous inspection noted that these meetings involved service users in all aspects of the life of the home. Staff were observed checking things out with service users during the day. A number of records were inspected such as care, medication, accidents/incidents and staffing records, maintenance and health and safety check records were also inspected. They were generally well organised. Safety checks for water, the fire system, gas and electric systems and mobile equipment such as wheelchairs and the homes transport, were all up-to-date. Mrs Law has not yet had time to review all policies and procedures but was indicated that she would be doing so. The OT was due to visit with regards to changing a walking-in shower with an adapted bath. It was suggested that the OT be asked to also risk assess the pads used in one bed with bedsides to rule out risk of suffocation. Significant gaps were found in important health and safety training areas such as fire and medication training, giving raise to a requirement. It was suggested that the training matrix should include the date when updates are due and that the fire training record should highlight whom the night staff are. The record used to document weekly fire points checks should also include a column for the fire and exit doors to evidence that they had been checked and action taken when a door does not open or close as intended. Environmental Risk Assessments are conducted and reviewed when needed. The flooring in the shower room has become unstuck in various places through wear and tear. This is likely to deteriorate and should be replaced as recommended by the previous inspector. Materials and equipment for the control of spread of infection was available and staff were observed using protective clothing to serve food. The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 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 2 3 3 3 3 X 3 2 X The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 Requirement The home must ensure that a robust pre-admission assessment process is conducted and evidenced, with the involvement of the service user and advocates, and it should be located in the service user’s individual file. This was a requirement of the last two inspections. All staff dealing with medication must be provided with appropriate training in the care of medicines and the necessary updates. The problematic odour in a private WC must be corrected. All staff must be provided with fire instruction, updates and all other mandatory training and updates. Timescale for action 31/10/06 2 YA20 13(6) 30/11/06 3 4. YA30 YA42 23(2)(d) 23(4) 31/10/06 31/12/06 The Minster DS0000059630.V312473.R01.S.doc Version 5.2 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. Refer to Standard YA6 Good Practice Recommendations Care Plans, their review and risk assessments all should be signed by the service user or their advocate to evidence their agreement. This was a recommendation of the last two inspections. All cash and financial records, including all PO and bank accounts for each person should be kept together so that there is a clear trail for audit purposes of moneys received and spent. This was a recommendation of the last two inspections. It is recommended that action is taken to bring the level of staff trained at NVQ to meet the 50 minimum standard. The floor of the shower room has become unstuck and worn (giving rise to air bubbles) on the central area. It should be replaced, as it is likely to deteriorate further and become unsafe. 2 YA7 3 4. YA32 YA42 The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 The Minster DS0000059630.V312473.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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