Inspection on 03/08/05 for The Minster

This inspection was carried out on 3rd August 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 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 27/09/06

The Minster 13/02/06

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 TA6 6LX Lead Inspector David Kidner Announced 3 August 2005 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 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 Stationary 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 D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 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 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 1. People aged 18-64 with learning disabilities. registration, with number 2. People aged 18-64 with physical disabilities. of places The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 10 persons in categories LD and PD. Date of last inspection 9 March 2005 Brief Description of the Service: The Minster is registered with the Commission for Social Care and Inspection to accommodate ten service users with a learning disability and associated physical needs. The home opened on the 6th January 2003. 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. The home 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 home has ten single bedrooms that all have en-suite accommodation. The home is decorated and furnished to a high standard with an extensive rear garden and patio area. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Announced Inspection was conducted over one day (8.00hrs). The Inspector would like to thank the service users, registered manager 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 seven service users were living at the home. There were three vacancies. The Inspector viewed all parts of the home; viewed records in relation to care and support plans, staff recruitment, health and safety and medicines records. The Inspector met all of the service users and sat and had lunch with a number of service users and staff. The Inspector spoke to one parent who was visiting the home at the time of the inspection. Five care staff were spoken to in private. The Inspector observed the staff team interacting with service users in a very professional, caring and supportive manner. The Inspector did not receive any comment cards from the service users. Voyage had notified all parents/relatives, Care Managers and Placing Authorities of the inspection and invited comments that would then be forwarded to the Inspector. The Inspector received 5 comments from parents and 1 comment from a Reviewing Officer. The majority of comments received were very complimentary of the services that are provided at the home. As a result of this inspection the home received one requirement and five recommendations. What the service does well: The home provides a high standard of accommodation and facilities. It is centrally located in the heart of a small village that provides easy access to local 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 floor areas. As previously stated the home does not have a passenger lift. The rear garden and other outdoor areas are well maintained and nicely presented. All bedrooms are of single occupancy, some with full en-suite facilities and reflect individual preferences and needs. The home has many aids and adaptations to promote the independence of the service users. There are detailed care and support plans with risk assessments where needed. The care and support plans are reviewed on a regular basis with The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 Page 6 appropriate persons involved. All records were well maintained. Service users access a variety of health care professionals as and when needed. Following discussions with the care team and feedback from other interested stakeholders it is evident that the staff team are committed in providing a high standard of care. The team wish to provide service users with a variety of opportunities and experiences, choice, independence and involvement as much as possible. Staff receive training in alternative methods of communication. Voyage provides staff with a variety of training including mandatory training. There are good records kept in relation to staff training. The home maintains good records in relation to health and safety. What has improved since the last inspection? What they could do better: The home must develop a more detailed pre-admission assessment process to ensure that the home can meet the needs of prospective service users. The Registered Manager should ensure that staffing levels are kept under review and that adequate staff are deployed at the home at all times to meet the needs of the service users. This has been highlighted in the main body of the report. The home should ensure that care plans are signed and dated by the service user, Registered Manager or other interested stakeholders, if appropriate to clarifyfy the agreement of the plan of care and support to each service user. Care plans should include any restrictions imposed in relation to the time service users go to bed of an evening or get up of a morning. The Registered Manager should consider that two staff signatures are obtained for all service users individual financial transactions and that detailed records are kept of service users bank details that demonstrate the breakdown of individual outgoing and personal allowances. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 Page 7 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 D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 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 standard(s) 2 3 4 The home does not ensure that a robust pre-admission assessment is conducted and recorded prior to new service users being admitted to the home. This must be addressed. EVIDENCE: Since the last inspection the home has admitted one service user. The service user moved from another home within the Company. The Inspector viewed the personal file and noted that a Care and Support Plan had been obtained. However, there was no documentary evidence to confirm that a formal assessment had been completed to ensure that the home could meet this person’s needs. It is the Inspectors opinion that the home must conduct a detailed assessment prior to any service user moving to the home, regardless if the service user is know to the Company. This was discussed with the Registered Manager at the time of the Inspection. It appears that the home does not have a formal pre-admission assessment format. The Inspector also spoke to the operational manager after the inspection and commented that this would be addressed. There was documentary evidence that the service user visited the home on three occasions and had an overnight stay. Care staff from The Minster visited the person’s previous home. The home had fitted an extra handrail on a stair area leading to the en-suite facilities as this was identified as a need prior to moving to the home. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 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 standard(s) 6 7 8 9 10 The care and support plans are user-led, well organised and reviewed on a regular basis. However, one care plan had not been signed or dated. This should be addressed. Risk Assessments are conducted and reviewed when needed. Service users are encouraged to make decisions about their life and are supported and encouraged to be involved in the running of the home. The home uses alternative methods of communication to offer choice and decision making. The home keeps good records in relation to the management of service users finances. There were lengthy discussions in relation to the setting up of individual bank accounts. Voyage is in the process of setting up individual bank accounts on behalf of service users. The home promotes confidentiality. EVIDENCE: The Inspector viewed three care plans including the care plan of the most recent admission to the home. Each service user has a nominated key worker. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 Page 11 The care and support plans were detailed and comprehensive. The parent of one service user stated that they are involved in their relatives’ plan of care and are consulted on a regular basis. Reviews occur on a monthly basis with summaries kept that detail the outcomes for individuals. Care Plans are formally reviewed on an annual basis in a multi-disciplinary type review. Behaviour Management Guidelines were in evidence where needed and signed by the Registered Manager. Risk Assessments have been reviewed and updated as needed. The Inspector noted that visits to all health care professionals had been well documented. These included visits to the GP and Consultant Psychiatrist. The Inspector noted that one of the care plans had not been signed by the Registered Manager or other interested stakeholders. This should be addressed. At the time of the inspection it was noted that service users were being offered choices in many aspects of daily living. Staff use Somerset Total Communication for some service users. Some staff will be receiving training in Intensive Interaction. Signs and Symbols are also used where needed. The inspector spoke to a number of staff at the time of the inspection. They clearly demonstrated how service users are offered choices in all aspects of daily living. The Inspector viewed and discussed the arrangements for the management of service user’s finances. The relatives of two service users manage their finances. The relatives provide monies and the home keeps well documented records relating to these finances. Currently five service users have individual building society accounts. The Inspector viewed the documentation of two service users finances. Daily records are kept of all transactions with receipts kept. The Inspector recommends that where possible two staff signatures are obtained. The balances of two service users were checked and found to be correct. Voyage is in the process of arranging individual bank accounts for the five service users. It is expected that these individual accounts will be in operation by the end of August 2005. Named staff members will be able to draw cheques from individual bank accounts on behalf of the service user. Protocols have been developed in relation to the limitations and company guidelines relating to the withdrawal of monies on behalf of the service user. This is good practice. The Registered Manager should give consideration of records being kept at the home in relation to the total breakdown of individual deposits and withdrawals in the bank accounts. This will then inform the service user, family members or advocates of their personal allowances and expenditures. The Inspector will further view service users finances at the next inspection when all bank accounts will be in operation. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 Page 12 The home has a confidentiality policy and all records are kept securely. Staff that the inspector spoke to demonstrated an awareness of the need to maintain and promote confidentiality. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 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 standard(s) 12 13 14 15 16 17 The home encourages and supports service users to access the local community and to partake in a variety of leisure, recreational and social activities. The home encourages family and friends to visit the home and service user rights are respected and promoted. The home has a planned menu that is healthy and choices are offered. EVIDENCE: It was evident at the time of the inspection that service users are offered choices in leisure, social and recreational activities. At the time of the inspection some service users were being accompanied to access leisure and social activities. One service user was going out to lunch with a parent. Activities are based on individual choice/need and records are kept of all activities that are undertaken. The Inspector spoke to a number of staff and they confirmed that the service users access a wide range of activities such as swimming, bowling, pubs, walks, cafes and day trips. They also commented The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 Page 14 that service users are accessing local facilities in the village more often now that staffing levels are beginning to improve. The home encourages contact with family members and friends. Records are kept of all visits and contacts. As previously mentioned the Inspector met with a parent of one service user. Positive feedback was received from the parent. It was evident that the home strives to develop good relationships with families and friends. The Inspector also noted a number of thank you letters and cards from family members. Service users have total access to the home’s premises. Each bedroom has a keypad to promote privacy. The home has ramps to areas of the home to ensure there is appropriate access for wheelchair users. Service users are involved in cooking, cleaning and household tasks according to individual need. The home operates a five week menu. Wherever possible service users are involved in menu planning and can request an alternative meal if so wished. The Inspector witnessed this at lunchtime, as service users were being offered another choice of meal and a choice in deserts. The mealtime appeared quite relaxed and unhurried. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 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 standard(s) 18 19 20 It was unclear that any restrictions that have been agreed in relation to service users times for going to bed and getting up are identified in individual care and support plans. The home provides technical aids and equipment to promote independence. The home ensures that service users have access to all appropriate health care professionals. The home maintains good records in relation to the administration of medicines. EVIDENCE: The Inspector noted that the home has aids and equipment to promote independence. Moving and Handling needs are identified in individual care plans where needed. The Inspector viewed risk assessments in relation to Moving and Handling. These had been reviewed and dated. One service user was using specialist eating and drinking equipment. The Inspector is aware that the staff team have been encouraging one particular service user to use this equipment. This has had excellent results as the service user has gained significant independence in this area. It was very pleasing to see the progress that the service user has made. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 Page 16 The Inspector noted that items on the agenda for the forthcoming staff meeting included the times that service users get up and go to bed. Following discussions with a total of six care staff the Inspector was advised that service users are not woken early on a morning to get up and that they can choose when to go to bed. It appears that some clarification and discussion was to be held with the staff team as to this matter. Standard 18 of The National Minimum Standards clearly state that; Times for getting up/going to bed, baths, meals and other activities are flexible (including evenings and weekends), subject to restrictions agreed in the individual plan (Standards 2 and 6 refer). The Inspector is aware that one or two service users choose to go to bed early and get up early. As good practice it is recommended that where this is the case, and as part of the agreed care package, that this is documented in individual care plans and kept under review The care and support plans that were viewed contained documentation of the visits made to health care professionals. These included visits to the GP, dentist, chiropodist, optician, speech and language therapist, physiotherapist and consultant psychiatrist. Records are kept of all visits and consultations. It was noted that two of the care plans had not been signed or dated by the service user, Registered Manager or other interested stakeholders, if appropriate. This should be addressed so as to clarify the agreement of the plan of care and support to each service user. The home uses the Boots Monitored Dosage System. The Inspector viewed the arrangements in relation to the storage and administration of medicines. This was satisfactory. MAR sheets were very well maintained. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 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 standard(s) 22 23 The home has a detailed complaints procedure and there are policies and procedures in place to safeguard vulnerable service users. EVIDENCE: A record is kept of complaints that are received at the home. There have not been any complaints since the last inspection. The home has a number of systems to safeguard vulnerable people. There is a copy of the Safeguarding Vulnerable Adults procedure. The home has previously taken appropriate steps in relation to the safeguarding of vulnerable adults when needed and has kept the Commission for Social Care Inspection informed. The Inspector spoke to a number of staff including a very recently appointed staff members. All staff were aware of the home’s Whistle blowing Policy and Complaints Policy. All prospective staff has a POVA check and an Enhanced CRB clearance before being employed to work at the home. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 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 standard(s) 24 25 26 27 28 29 30 The home is fully accessible and designed to meet the needs of the service users as stated in the home’s statement of purpose. Bedrooms are beautifully decorated and maintained and reflect individual needs and lifestyles. Eight of the ten bedrooms have full en-suite facilities. The shared bathroom and toilet facilities are very well presented and have specialist equipment installed where needed. The shared space is well maintained and is fully accessible to all service users. The home has lots of specialised equipment to maximise independence. On the day of the inspection the home was very clean and tidy. EVIDENCE: The Minster is very well presented and is furnished and decorated in keeping with the age and style of the property. The Registered Manager stated that the lounge and dining room is to be decorated in the near future. The home felt relaxed and very homely. The Minster does not have a passenger lift to the first floor. However, there are bedrooms on the ground floor. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 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 rear garden. There are many aids and adaptations around the home. All bedrooms are of single occupancy. They were very nicely decorated and furnished and contained personal possessions including family photographs, pictures, ornaments, television, hi-fi and DVD players. The shared bathroom and toilet facilities were very well presented and have specialist equipment installed where needed. On the day of the inspection all areas of the home were clean, hygienic and tidy, but still retained a very homely atmosphere. The home has adequate laundry facilities. All cleaning agents are always kept in a locked cupboard in the laundry room. The home has a cleaning schedule. On the day of the inspection it was noted that all areas of the home were very clean and hygienic. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 33 34 35 36 On the day of the inspection the home appeared appropriately staffed to meet the needs of the service users. However, the Registered Manager must ensure that there is adequate staff on duty to meet the needs of the service users at all times. Voyage has a commitment to provide staff with the knowledge and skills to promote and maintain a well-trained workforce. Voyage has a robust recruitment process and staff receive formal supervision and appraisals. EVIDENCE: The home has experienced severe recruitment difficulties in the past and it appears that the situation is gradually improving and further staff have been appointed. Care staff commented that staffing levels have improved and that they have been able to accompany service users in activities in and out of the home including accessing facilities in the local community. There is usually a minimum of four staff on duty at all times, however, on the odd occasion this has fallen to three staff. The Registered Manager confirmed that recruitment has improved and that staff are appointed as soon as possible following interview and appropriate protocols. Following discussions with the Registered Manager it is recommended that clarification be sought in relation to the The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 Page 21 allocated staffing hours for the home and to establish the current vacancy factor in relation to the number of service users currently living at the home. It appears that there are vacancies for care staff both for daytime and evening hours. It is expected that there may be new admissions to the home in the near future. Consideration should be given as to when there are new admissions as there should be an adequate staff team in place. The Registered Manager acknowledged this. The Inspector viewed the recruitment files of recently appointed staff members. The files contained the required documentation. The home keeps a record of all training that has been undertaken. Any gaps in training are noted and staff will undertake required training as soon as possible. Newly appointed staff undertake the Learning Disability Award Framework training and staff are undertaking NVQ2 and NVQ3 Qualification. Training that staff have attended include, Food Hygiene, First Aid, Manual Handling, Protection of Vulnerable Adults, Stress Management, and Health and Safety Training. Some staff have also received training in Somerset Total Communication and Intensive Interaction. The Registered Manager and staff that the inspector spoke to confirmed that Voyage has a commitment to provide staff training and that courses are readily available. Staff confirmed that they receive regular supervision with records kept of discussions and outcomes. The Inspector did not view documentation in relation to this at the time of the inspection. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 38 40 41 42 The Registered Manager is qualified, competent and experienced to run the home and shows direction and leadership. Voyage has a clear management structure and comprehensive Policies and Procedures. All policies and procedures are available in the home. The home strives to promote all matters relating to health and safety. EVIDENCE: The Registered Manager is Nicola Rossenrode who has a HNC in Social Care and a Diploma in General Nursing and has previous experience working with people with a learning disability. Nicola achieved the Registered Managers Award in October 2003 and has also achieved D32 / 33 NVQ Assessors Award qualification. The Inspector spoke in private to a number of care staff. Care staff commented that Nicola is approachable, listens, shows direction and is supportive and that residents come first. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 Page 23 All records sampled were well presented and maintained and held in a secure and confidential manner. Voyage has comprehensive Policies and Procedures. The Inspector viewed documents and records relating to health and safety. The home has developed and maintained very good recording and filing systems. All appropriate checks are undertaken including weekly checks of the fire alarm system, emergency lighting, fire equipment and torches. Records are kept of fridge and freezer temperatures and hot water temperatures. Environmental Risk Assessments are conducted and reviewed when needed. The Inspector noted that the flooring in the shower room was beginning to bubble up. The Registered Manager stated that this has been reported to the maintenance team. The home keeps records of all incidents and accidents and monthly reports are complied by the Registered Manager and sent to Voyage Head Office in Taunton for further audit. This is good practice. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 1 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 2 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 2 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Minster Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 3 x D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 Page 25 Are there any outstanding requirements from the last inspection? No 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 detailed pre-admission assessment process is conducted to ensure that the home can meet the needs of prospective new admissions to the home. Timescale for action 30/09/05 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 It was noted that one care plan that the inspector viewed had not been signed or dated by the service user, Registered Manager or other interested stakeholders, if appropriate. This should be addressed so as to clarify the agreement of the plan of care and support to each service user. The Registered Manager should consider that two staff signatures are obtained for all service users individual financial transactions. The Registered Manager should consider keeping individual records of service users individual bank accounts so as to demonstrate the breakdown of individual charges and personal allowances. This will then infrom the service user and other interest stakeholders, if appropriate of individual income and expenditure from this account. D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 Page 26 2. 3. YA7 YA7 The Minster 4. YA18 5. YA33 The Registered Manager should ensure that any restrictions that have been agreed in relation to service users times for going to bed and getting up are identified in individual care and support plans. The Registered Manager should ensure that staffing levels are kept under review and that adequate staff are deployed at the home at all times to meet the needs of the service users. The Minster D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier, 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 D53_D02 S59630 The Minster V232595 030805 Stage 4.doc Version 1.30 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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