Inspection on 25/07/05 for The New Bungalow

This inspection was carried out on 25th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The New Bungalow 15/05/07

The New Bungalow 30/10/06

The New Bungalow 09/02/06

The New Bungalow 19/01/05

The New Bungalow 03/06/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Sutton Lodge Nursing Home

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 The New Bungalow Forge Hill Aldington Ashford, Kent TN25 7DT Lead Inspector Lois Tozer Unannounced 25 July 2005 9:30 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 New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The New Bungalow Address Forge Hill, Aldington, Ashford, Kent, TN25 7DT 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) 01233 721222 Canterbury Oast Trust Care home only 6 Category(ies) of Learning Disability x 6 registration, with number of places The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2005 Brief Description of the Service: The New Bungalow is registered to provide accommodation, personal care, and support to a maximum of six people with learning disabilities who may also have a physical disability. The premises is a purpose built, single story bungalow which is approximately 15 minutes walk from the village shop and 10 minutes from the local pub. It is owned and operated by The Canterbury Oast Trust (C.O.T.), a charitable organisation and is managed by Mrs Judith Jones. Situated in an attractive rural location overlooking Romney Marsh, the bungalow is set back from the road and neighbours another C.O.T. premises. Communal areas are limited to one very large lounge and a kitchen diner. All bedrooms are registered for single occupancy. Staff have their own dedicated sleep-in facilities within the office areas. Access into the wider community relies on the homes transport (the public bus service being reported as infrequent). There is one dedicated, wheelchair accessible vehicle for communal use. A woodland management project operated by C.O.T. is situated nearby; this is used for service user work experience and recreational use and is also open to the public. The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory announced inspection took place on 25th July 2005 between 9.40am and 6.30pm. The manager, Mrs Judith Jones, has been in post since February 2005 and is currently in her probationary period. The manager and staff willingly assisted the inspection process throughout the day. There are currently five people living at the home, feedback was gathered from three residents through observation of activities, interactions with staff and discussion with a visiting relative. Paperwork seen included individual support plans, risk assessments; medication and administration documents; communication book, fire, health and safety documentation, complaints information, training details, duty rota, and menu. The bungalow is a pleasant, well-presented abode set behind another C.O.T. property and shares a large garden. A patio has been built to the rear of the house and features a swing seat and garden furniture. Work is planned to replace the bathroom suite, but as yet, no firm date has been set, which has created an ongoing restriction for several people living at the home. Five relatives feedback cards were received, these indicated that the service was improving and was meeting people’s needs in a more proactive way. Positive statements include;‘The Bungalow is now managed far more effectively than it ever has been. After a very bad time, I am now very happy with X care.’ ‘ Since the appointment in Feb 05 of Judith Jones as the new home manager, the atmosphere and morale of the staff has improved dramatically, and hence the quality of the care of the residents.’ ‘[My daughter] is very well placed here, she knows where is, seems to like the surroundings and is very happy’. Three care manager comment cards were received, and these too supported a perceived positive change, with comments as follows; ‘With a change of manager earlier this year, progress is being made and the staff group appear far more stable. Am confident good progress can be made in coming months’. ‘Have had concerns in recent past regarding unfulfilled staff posts, use of agency and in general the cohesiveness of staff team’. This does appear to be improving and new staff have been recruited’. ‘Service user plans are being written by new manager, review of previous goals are being evaluated regularly’. ‘Impressed by the new manager she is very client centered and working with existing staff to promote choice and independence’. What the service does well: As a purpose built home, it is wheelchair accessible throughout, and persons who use wheelchairs within the home are able to get around unaided. Residents are supported to make choices and staff were seen to be listening to The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 Page 6 the people using a variety of methods, especially facial expression and body language. The use of Makaton was being promoted, and this appeared to have a positive effect on the people who found verbal communication difficult. Staff are provided in sufficient numbers to meet the needs of the service users, and they have received a wide range of health and safety training. Meal times are a very pleasant time, and residents are encouraged to come in and have a look at the meal preparation, although, are not at this stage, involved directly with the cooking. Staff support people considerately when helping them to have meals and present liquidised food in an attractive way. What has improved since the last inspection? What they could do better: It is noteworthy that there are no outstanding requirements from the last inspection, but as the manager has only been appointed for a short period of time, it is understandable that this inspection has generated a range of requirements. Most importantly, the service users individual strength and need assessments and plans need further development. They have improved, but are still rather vague in important areas, such as mealtime assistance. Risk assessments are in place, but these are long winded and do not get to the heart of the matter – is the activity or event beneficial to the person and what action is required to reduce the risk so the event can take place. Some areas posing a risk to both staff and residents (banking using chip & pin cards), have not been assessed at all. As the people using the service have limited communication skills and rely heavily on staff support, it is essential, for continuity of care, that the way a person is to be supported, is crystal clear. Staff training is provided readily for health and safety matters, but is lacking in the areas concerning activities, engagement, respect and empowerment of the people living at the home. Induction training would benefit from a greater The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 Page 7 focus on people with learning disabilities and complex needs. Some medication management shortfalls were seen, this also raises the question, is the training provided meeting the needs of the service? Environmentally, the home has one bathroom and one shower room. The bath was identified over 12 months ago as not meeting several peoples needs, but no date for refurbishment has been set. The bath itself is now worn and has a sandpaper like texture, so requires addressing in the very near future. A comment received indicated that this wait is unacceptable; ‘…however the issue of not having a usable bath persists and this facility rather than just showers are essential for some residents’. 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 New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 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 New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 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) 1, 2, 5 The service user guide is full of valuable information to aid prospective service users to decide if the home is suitable for them. The assessment process has not been used for many years, but the past procedures have been robust. It would be beneficial for all residents to have a repeat needs assessment to complement the support plan reviewing process (standard 6). Individual written contracts state the terms and conditions of residency in a manner that could be understood by service users with some support. EVIDENCE: A revised and very informative statement of purpose and service user guide has been developed and contains all the information a prospective resident requires to make a decision if the home can meet their needs. This has been presented in a pictorial manner that could be accessible to the residents with support. A copy is required to be sent to the Commission. All new service users would undergo a full needs assessment prior to a placement being considered, and documentation previously seen demonstrated that this covers the range of this standard. The home has a stable resident group and as such has not had any new admissions for many years. It is recommended that the new manager conduct assessment for each existing person living at the home to complement the work required on the individual plans, standard 6. Work already completed on strengths and needs must be accurate and specific, one seen was quite muddled, indicating a staff training need. The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 Page 10 A recent piece of work on contracts has provided each individual with an easy to read and understand statement of their terms and conditions of residency, using symbols and pictures where this aids understanding. The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8, 9, 10 Work continues to take place to develop personal plans that reflect individual strength and need. Opportunities for residents to make decisions, ways of consultation and participation in the daily routines of the home have improved. Risk assessments are in place but are long winded and do not clearly identify the action required to reduce risk. Storage of confidential and sensitive information has improved. EVIDENCE: The home has been working on the development of individual plans, and there is a degree of improvement, information is now more up to date, but the coherence of the documentation needs further work. It is important that individual persons strengths and needs are clearly identified and specific support requirements are made unambiguous. Risk assessments relating to any care needs are quite ‘fuzzy’ and do not give practical advice. These should be linked to the support plan and offer the reader instruction on what action should be taken to reduce risk. Where risk of physical intervention exists, this too must be well documented and staff limitations are also made clear. It was encouraging to see the people living at the home being actively involved in day-to-day duties, especially around the kitchen. Staff were actively encouraging residents to express themselves, for example, the desire for a second drink, and were using Makaton signing to reinforce the decision. The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 Page 12 Confidential and sensitive information is no longer recorded in the communication book. The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 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) 11, 12, 13, 14, 15, 16, 17 Resident’s personal development opportunities have improved since the last inspection. Activities are offered that attempt to captivate interest and that will be accepted by the individual. Although the home is situated in a rural location, trips into the village and wider community are facilitated. A range of leisure activities enjoyed by individuals is offered, and work to extend this range is ongoing. Residents are supported to maintain close family connections and have fulfilling relationships. Residents are being supported to take a more active role in the home, and enjoy a varied and healthy range of food. EVIDENCE: The manager recognises that greater development to enable opportunities for the people in the service to take an active role in the community is needed. Access has improved, an adaptation to a wheelchair, to house a motor, has been purchased, enabling staff to get up the local hill into the village with one resident. Improvements have taken place across all these standards, and the manager has a clear vision as how these will continue to improve. Research into other adaptations to enable more people freedom without using the minibus is currently taking place. Residents appeared collectively more The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 Page 14 empowered and were clearly making their needs known to staff by leading them or by actually entering the kitchen to indicate, which is a great step forward. A relative visiting at the time said that they were very pleased with the way the home provided care and staff were always very welcoming and accommodating. There is a wide range of sensory equipment that staff use with each person. Lots of variety is offered on the menu, and where possible, foodstuffs are homemade. Liquidised food is presented in an attractive manner, and individuals are encouraged to feed themselves, however staff were seen to give thickened drinks from a kitchen jug rather than an appropriate drinking vessel, which must be discontinued. The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 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 Improvements to specify how staff should provide personal care are required. Physical and emotional support has improved. Medication management has some shortfalls which must be addressed. EVIDENCE: The manner in which a person needs support for areas such as eating, need greater development, especially when this requires a degree of persuasion. Support plans were vague and staff described a variety of ways that they would support a particular person, stating that they had learnt such methods from shadowing other staff members. Staff must be supported by documentation that specifies exactly how to assist a person, especially where people are unable to verbally state their wishes. It is essential that documentation give continuity of approach to enable accurate reviewing. Some of the plans seen had improved, for example, bathing, and were much more specific than previously noted. The manager is working with the team to create a holistically supportive home for the people living in it, including appropriate emotional support. Using the review of needs as recommended in standard 2, these areas would benefit from greater, identification. Medication was examined and several shortfalls were found. Staff do receive training, however, it is an intensive ½ day. With mistakes occurring as follows, the manager must examine if the training provided actually meets the needs of the service. Refused medication was in contained in a bag, with a slip of dated paper stating the name of the tablet. It was not logged in the returns The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 Page 16 book, as this was at the pharmacy (this document must be retained by the home). It was not documented on the MAR sheet, and had been signed as given for the date indicated. There was no clear system for safe disposal. A competency assessment has been developed, but has not been signed off by the manager to denote if the candidate was or was not competent. Some of the answers indicated a learning need. It is strongly recommended that a list of desired outcomes to the questions be available. Also recommended is that a ‘count back’ system be put in place for medication that comes in the standard boxes and a cover sheet for each persons medication be available stating what each medication is for and the common side effects. The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 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 Improvements in communication between staff and service users through the development of relationships and use of Makaton indicate that views will be listened to. Many staff have received adult protection training, and understand the procedure. One element of protection, finance, requires risk assessment. EVIDENCE: Due to the nature of the disabilities of the people living at the home, it is extremely difficult for them to express their specific views. Staff were seen to be responsive to individuals moods and changes in body language as well as using Makaton to confirm the wishes of service users. Adult protection training has been received by the majority of the team, with a rolling rota to provide new staff with this opportunity. External complaints are recorded and documented and acted upon. One recent complaint showed a positive resolution, although it was not concluded in writing to the complainant, which is strongly recommended. Canterbury Oast Trust have assisted service users to open up individual bank accounts, and receive their personal benefits by direct payments, this is a met requirement of previous inspections. Each individual has a monthly statement from the bank, however access to cash is via a ‘chip & pin’ card. Where individual residents can memorise and keep the pin number safe, this is a really effective set up, but no assessment of this ability has taken place. Assessment of risk is absent, and this current situation leaves both residents and staff vulnerable. A requirement to assess the situation and make the necessary changes to improve the safety (such as access to a cheque book) has been made. In the meantime, positive steps have taken place, the manager has implemented a robust, access-limited accounting system for any money withdrawn on individuals behalf and money held by the home is well accounted and audited regularly. The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 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 comfortable, homely, and safe. Bedrooms are highly personalised and seem to be enjoyed by the individuals. Shared space is limited to one large room, but meets all the resident’s needs and is well maintained. Adaptations that have been assessed as necessary for physical movement have been implemented, but further assessment may be of benefit to increase the level of wheelchair access outside of the home. Improvements in both bathrooms have been identified as required, but no date of commencement has been made; this has placed a limitation on who can use the bath. EVIDENCE: The home is a purpose built bungalow with all facilities over one floor. Staff take the lead responsibility for domestic chores, and are working towards the greater inclusion of residents in more aspects of running the home. The bathroom was identified, prior to June 2004, as needing refurbishment as it does not meet service user needs. The bath itself has a rough surface where the enamel has worn away. The physical structure of the room makes accessibility difficult for persons who need to use a hoist. The ceiling has some discolouration. A requirement to identify the timescale to address this has been made. The shower room remains uninviting, as it has no windows and a darkly stained floor, and had been used, at the time of inspection, for hosing The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 Page 19 down a wheelchair. Bedrooms and other parts of the house are in generally good order, but a large crack was appearing on the lounge ceiling that had not been previously seen by the manager. There are some plans to increase the communal space, which would be of benefit, as currently there is only one room, making getting away from others difficult. The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 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) 33, 35, 36 Staff are available in sufficient numbers to meet assessed needs and have received lots of health and safety training, but would benefit from greater provision in relation to working with the specific service user group. Supervision frequency has improved and a rolling schedule is now in place. EVIDENCE: Records showed that staff receive a wide variety of training to meet service users health needs (epilepsy awareness and management, medication, manual handling, health and safety, first aid, adult protection, infection control), but none of these are designed to teach staff about the methods of engaging people in meaningful activities or about the specific care needs as a result of individual conditions. Staff clearly showed a real commitment to meeting peoples needs, but as seen in standard 17, also showed a lack of awareness when helping a person have a drink from a kitchen measuring jug. It is required that the manager audit the staff skills in relation to the developmental needs of the residents and assess if the TOPSS induction training is sufficiently in depth to prepare new staff to work with complex people. The NMS recommend that staff working with people who have a learning disability receive LDAF accredited training. Training adequacy for medication management should also be assessed to ensure the provision meets the service needs. The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 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 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, 39, 42 The home has benefited from the skills and experience of a new manager. A more service user focused approach and ethos is being cascaded though the team, with demonstrated improvements for the residents. Some quality assurance measures are in place, but greater cohesion and development against the standard would provide evidence that the service is being developed in the manner that achieves the best for the people living there. Provision of a safe environment has improved since the last inspection. EVIDENCE: Since taking post in February 2005, the manager has prioritised areas of necessary development with a focus on outcomes for the people living at the home. Staff were open and positive about the way the home is now managed and were keen to say that they very much enjoyed providing a quality service for the residents. The manager, who has a wide variety of ideas as how to improve and develop the service, has already noted many of the issues and requirements identified in this inspection. Quality assurance measures, such as staff supervision, monthly visits by the area manager, questionnaires to significant people in the residents lives and so on are in place, but there is little The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 Page 22 cohesion to bring these elements together to form a robust development plan, which is required. Other than the bathroom suitability, the service is generally well maintained and equipment receives regular, documented servicing. Staff, as noted, have a wide range of health and safety training, and much of this is covered at their TOPSS induction training. Risk management has improved, but much of this has unfortunately come about in a re-active manner after incidents have occurred. Fire detection and prevention systems had lapsed, but have now been audited and corrected. The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 x x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 1 3 2 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score x x x x 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The New Bungalow Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 3 2 x x 3 x H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 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. 2. Standard YA1 YA6 to YA18 Regulation 4, 5 12 (3, 4) 14; 15; 17 (1,a),18 (1, a) Requirement Submit copy of the statement of purpose and service user guide. Development of comprehensive care and support plans that are specific to each individuals strength and needs, consulting with the individual where at all possible. Personal care and support needs must be specific and be linked to the risk assessment process where necessary. Risk assessments must be specific, user friendly and give clear actions to reduce risk. Provide thickened drinks in drinking vessel. Revise medicaion policy and procedure for spoilt medicaion. Review training provision to ensure it meets the needs of the service. Risk assess service user access to money using the ‘chip & pin’ facility, taking action to remedy if required. Advise Commission the planned date for bathroom refubishment. Induction training to cover the needs of the people being Timescale for action 01/10/05 01/10/05 3. 4. 5. YA9 YA17 YA20 13 (4,b, c) 12 (4,a), 18 (1,b) 13 (2), 18 (1,c[i]) 01/10/05 29/08/05 29/08/05 6. YA9 & YA23 13 (4,b) 01/09/05 7. 8. YA27 YA35 23 (1,a; 2, a, c, j, n) 14 (1,a & 2, a, b) 15/08/05 01/11/05 Page 25 The New Bungalow H56-H05 S23568 The New Bungalow V232925 250705 Stage 4.doc Version 1.40 18 (1, ac, [i & ii]) 9. 10. YA37 YA39 9 24 (1-3) supported, ie LDAF. Audit the training provision against the assessed needs of the service users and provide training to meet the needs accordingly. Manager to apply for registration 01/10/05 ASAP after probationary period is completed, but by... Develop an inclusive, robust, 01/12/05 quality assurance monitoring system against the elements of this standard. 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. Refer to Standard YA2 YA20 Good Practice Recommendations Exisiting persons living at the home have a needs assessment conducted to enable more comprehensive care and support planning. Count-back system for medicaion that is not supplied in the pharmacy MDS system. Cover sheet for each persons meds stating what it is used for and the common side effects to look for. Compentency assessment to be signed of by the manager to indicate if the individual is actually competent or not. Respond to complaints in writing, keeping a copy on file. 3. 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