Inspection on 13/02/07 for The Old Police House

This inspection was carried out on 13th February 2007.

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 Old Police House 16/02/09

The Old Police House 09/02/06

The Old Police House 23/08/05

The Old Police House 09/02/05

The Old Police House 23/09/04

The Old Police House 16/07/02

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Old Police House The Old Police House Nunney Frome Somerset BA11 4NE Lead Inspector Pippa Greed Unannounced Inspection 13th February 2007 09:10 The Old Police House DS0000030144.V325101.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 Old Police House DS0000030144.V325101.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 Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Police House Address The Old Police House Nunney Frome Somerset BA11 4NE 01823 423126 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) gguy@somerset.gov.uk Somerset County Council (LD Services) Care Home 8 Category(ies) of Learning disability (0), Physical disability (0), registration, with number Sensory impairment (0) of places The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users may have concurrent physical disabilities and/or sensory impairment. Service users over the age of 65 are permitted to remain in the home. Date of last inspection 9th February 2006 Brief Description of the Service: The Old Police House provides care and support for up to eight adults who have learning disabilities and associated physical and sensory impairments. In addition, a high level of support is required with communication needs. The home is situated on the edge of the village of Nunney. The accommodation is arranged on two floors and includes single bedrooms for all. The building has been adapted in the past to accommodate people with additional care and support needs. The ground floor accommodation is fully accessible and comprises six bedrooms, two bathrooms and communal space. Two further bedrooms are located on the first floor, which is accessed by a stairway. The property has an enclosed garden area at the rear. A team of staff throughout the 24-hour period supports the people who live at The Old Police House. Staff provide support in maintaining links with families, who are encouraged to remain involved in the lives of those who live here. The home has its own transport. Those who live here are able to get out and about into the wider community, with staff support. The acting manager Michael Rhodes is currently applying to register with CSCI. The current fee is £1,212 per week. The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key inspection was conducted over one day (9hrs) by CSCI Regulation Inspector Pippa Greed. On the day of the inspection, three community care assistants (CCA), one support worker (SW – senior member of staff) and the manager were on duty. During the afternoon, there were two community care assistants and one support worker. There were two waking night staff rostered for that evening. The home also has a member of staff who cleans the home three hours a day, five days a week. The acting home manager was available to assist the inspector during the unannounced visit. On the day of the inspection eight service users were at home initially. Four service users left around mid morning to attend an ‘atmospherics’ session. The atmosphere was relaxed and informal. Staff were seen to work in a caring manner with the service users. The inspector viewed all communal areas and four service users rooms with their expressed consent. The inspector met with and engaged with five service users. The inspector sat with the service users and staff during lunchtime and observed daily routines within the home. The inspector met with three staff members to discuss their induction, supervision and training provision. The staff commented that they felt supported by the acting manager. A selection of records was examined. These included four service users care plan and four staff recruitment files. CSCI sent out feedback cards for four service users, eight staff, three relatives, and one General Practitioner. Two service user’s surveys were received. These were completed with advocated support and reflected overall positive comments. Two care staff comment cards confirmed that they are aware of organisational policies and receive regular supervision. One staff wrote that the home has a supportive staff team. Within one service user’s survey, one relative wrote ‘The staff at The Old Police House are very good and they do their job very well.’ The inspector would like to thank the service users, staff, and manager for their time and hospitality shown to the inspector during her visit. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: No requirements were made at the last inspection. Three recommendations were made on that occasion. These have not been implemented fully. These related to reviewing the frequency of moving and handling training for staff, updating service user’s care plan and consideration to be given to redecorating communal areas within the home. One requirement and a further five recommendations were made at this inspection. The training file evidenced that some staff mandatory training are in need of updating. It is required that staff are provided with mandatory training refresher. The recommendations made were in relation to service users contracts, the practice of two staff signatures to support all financial transactions and all hand transcribed entries on the Medication Administration Record, It is also recommended that the Complaint procedure make clear to the reader that statutory agencies can be contacted at any stage of the Complaint procedure and that all staff receive POVA training update as good practice. The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 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 summary of this inspection report can be made available in other formats on request. The Old Police House DS0000030144.V325101.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 Old Police House DS0000030144.V325101.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users and their families are provided with relevant information regarding the home. Social and health assessments are completed to ensure that the home is able to meet service users’ needs. EVIDENCE: The home has a Statement of Purpose that provides details of the services and facilities provided at The Old Police House. The Statement of Purpose is presently being updated to reflect the changes within the home. The service users contract is stored in the care plan. These identified weekly fee charged. However, these contracts were not dated. This is recommended. The Statement of Purpose outline criteria for admission. Prior to admission a needs assessment is undertaken by the social worker (care manager) involving the service user and carer or someone well known to them. The team leader will visit prospective service user at home to meet service user and family to discuss needs, and identify what support is needed. The prospective service user will usually spend some daytime hours in the home then gradual The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 10 overnight stays lengthening in time until full time admission is successfully completed. There is no set timescale as each case is judged on the service user’s needs. The Service Users Guide is provided in a simple easy to understand format. It also includes one section titled ‘Our Promises to You’, which has Somerset Total Communication symbols for ease of understanding. The Service User’s Guide covers the following: The House, Other People, Staff, Staying Here, Food, Going Out, Your Rights, Smoking, What it costs to live here and Our Promises to You. The Service Users Guide is stored in individual care plans, which promotes good practice. The people who live at the home have all lived there for a significant period of time. Although no pre-admission assessment was sampled, the home has adequate information available for any individual wishing to move in. Prospective service users are introduced to the service dependant on their needs and requirements. There is no vacancy at present. The Old Police House DS0000030144.V325101.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Sampled care plans were detailed. Service users are encouraged to exercise choice and participate in all aspects of life within the home. Service users are supported in taking risks. Records relating to service users are stored securely and appropriately maintained. EVIDENCE: The inspector sampled four service users care plans. The Care Plan outlined the following topics; People that matter to me, My personality, behaviour and relationship, Helping me to communicate, My Personal Care needs, Lifting & Handling (mobility), Health – keeping me well, Help I need to eat and drink. These provided clear information on the service user’s health, social and emotional need. However, it was noted that the Care Plan would need updating in order to reflect the service user’s changing needs. The last inspection The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 12 recommended changes to the systems of care planning. Somerset County Council have discussed the new format with the inspector but these have yet to be implemented. The home plans to update the Care Plan with a new Residential Support Plan, which is more structured and cohesive. The care plan file also included details relating to general health, dental care, optical care, and chiropody. These were detailed and evidenced regular care provided. The care plan file also included records of review meetings, visits to health care professionals, and contact with families. The manager informed the inspector that review meetings were held in recent months. The care plan file provided evidence of equal access through guidelines such as ‘How I want my support staff to go into my bedroom’. These practices were observed during the inspection process. These guidelines identify each service user preferences in relation to how staff should enter their bedroom such as knocking before entering. Finance risk assessments have been completed for each service user. These were supported with a letter identifying appropriate appointee. Service users are encouraged to exercise choice. This is done through individual communication system. The inspector observed staff interaction with service users during the inspection process. Staff were seen and heard to ask service user permission when administering medication or informing them of meal times. Staff were seen to provide a warm caring approach towards service users. Staff demonstrated their knowledge and understanding of service user’s moods, vocalisation, facial expression or body language, which indicated their chosen preference. The home also provides Communication Development Plan, which is designed to encourage service users and promotes their access through Speech Language Therapist, Total Communication and Intensive Interaction all of which enables the service users to make choices. The home keeps individual day to day records that detail the activities and choices that have been made by service users. Financial records were seen for three service users. One staff signature supported all entries, which were checked by manager or senior on a regular basis. The entries were correct for one service user and two had very minor discrepancies with the final balance. It is recommended as good practice that two staff signatures are recorded for all transactions. All records relating to service users are stored securely and recorded appropriately. The Old Police House DS0000030144.V325101.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home offers service users opportunities to engage with peers, access appropriate leisure activities, and exercise choice. Service users rights and responsibilities are respected. Service users are offered a choice of menu, and were seen to enjoy the meals provided. EVIDENCE: Staff from the home support service users continued access to social and leisure resources. On the day of the inspection, eight service users were at home. Four service users attended ‘atmospherics’ session during the morning. Service users were seen to participate in their preferred activities such as listening to music or carrying out daily living tasks. The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 14 Activities provided by the home and in the wider community includes the following: Gateway club, swimming, disco, skittles, ‘atmospherics’, gym, storytelling, music, beauty makeover, television and video, art & pottery, cookery, shopping, walks, and meals out. The service users who live at the home have complex needs and require support and assistance in all aspects of daily living. The inspector observed how support was offered during the day. Overall care was provided sensitively and appropriately. The inspector spent some time sitting in the dining room observing interaction by staff with service users. Service users were informed verbally or demonstrated to prior to medication being administered. Lunchtime routine was relaxed and unhurried. Service users were seen to be enjoying their meals, which were jacket potatoes, mixed vegetables and meat pie. There were positive interactions with service users. Care was taken to inform service user of what was going to happen. Staff were overall seen to be caring and considerate of service users needs at mealtime. The home provides a sensory room, which includes beanbags, floor cushions, tactile toys, fibre optics, ceiling decoration, rope light, music system, light projector and water bubble display. The home also organised a short holiday to Cornwall and Devon for six service users last year. The home strives to maintain regular contact with service users family members. Care plans provide details of service users personal and family relationships. There are many photographs of service users and their families in individual bedrooms. The inspector spoke with a family member who visited the home. The family member commented that the staff are very good and that their relative was well looked after. The family member said ‘I’m very happy with this home.’ The home has a menu that reflects the likes and dislikes of the service users. The meals offered for the day provided a balanced and nutritious diet. The dining room board depicts the meal for the day with simple symbols (Somerset Total Communication) and photographs. The Old Police House DS0000030144.V325101.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are provided with appropriate assistance to meet their personal care needs. The home supports service users in accessing healthcare services. The home has aids and adaptations to assist the service users in their personal support. The home promotes service user’s privacy and dignity. Medication Administration Records are managed safely. EVIDENCE: Service users are provided with support to undertake personal care tasks as required. Many service users have complex health care needs. Staff support service users in accessing healthcare services and ensure that specialist advice is sought as necessary. The care plans that were sampled contained documentation of the visits made to health care professionals. These included visits to the GP, dentist, chiropodist, and optician. The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 16 A record is maintained in care and support plans of healthcare appointments and outcomes. The home has aids and adaptations to assist the service users in their personal support. Service users have the use of technical aids and equipment where needed. The health and safety checks for these equipments are maintained regularly. The home provides three bathrooms, two of which are on the ground floor. One of which is a large assisted bathroom and the other is an assisted shower room, which provides appropriate support with personal care. No current service users are able to self-medicate. Service users medications were kept in their own bedrooms in a lockable cabinet. The inspector sampled the Medication Administration Record and storage of medication. This was considered well maintained. Three service users medications were sampled and checked. Storage areas were found clean and tidy. Medications were clearly labelled and dated when opened. Personal Protective Equipment (PPE) was provided for staff. Some minor gaps were seen on the Medication Administration Record. One staff member wrote medication details on the Medication Administration Record. It is recommended as good practice that two staff signatures support all hand transcribed entries. The home has a policy relating to ageing and death. The current care plans does not contain details relating to standard 21. The home intends to implement the proposed Residential Support Plan, which includes a section covering this standard. The Old Police House DS0000030144.V325101.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a clear Adult Protection policy, which is accessible. The home has systems in place to protect the service users from abuse. The home has a complaints procedure and policy relating to the Protection of Vulnerable Adults. However, the Somerset County Council ‘Whistleblowing’ leaflet does not include the Commission’s contact detail. EVIDENCE: The home has appropriate policies relating to the Protection of Vulnerable Adults, Whistleblowing, Complaints policy, and Grievance policy. These are kept in the staff office. Two staff comment cards were received. The inspector also spoke with three staff members. They confirmed they knew where Protection of Vulnerable Adults information is kept. They also stated that they understood how to report any concerns about poor care or allegations of abuse. POVA training has been offered to new staff members through induction training. However, it is recommended that all staff receive POVA training update as good practice. The manager informed the inspector that no complaints had been made since the last inspection. Similarly none has been reported directly to CSCI. The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 18 Whilst the home has a complaint log in place, the complaints policy should make clear to complainants that they are able to contact the Commission for Social Care Inspection at any stage of a complaint. Criminal Records Bureau (CRB) checks are in place for all staff. POVA 1st checks have been carried out on newly recruited staff. The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has been decorated and furnished to a good standard. The home has sufficient communal areas and bathrooms to meet service users’ needs. The home was found to have a good standard of cleanliness. EVIDENCE: The Old Police House is a large 1930’s style house situated in a semi-rural setting in the village of Nunney. All rooms are single occupancy with en-suite washbasins. Six bedrooms are situated on the ground floor and are wheelchair accessible. Two bedrooms are situated on the first floor adjacent to a shared bathroom. This bathroom has been recently redecorated and appears welcoming. The accommodation also includes a large comfortable lounge, dining room, multi-sensory area, two ground floor bathrooms adapted to meet service users needs, including a The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 20 Jacuzzi bath and whirlpool bath. One of the bathrooms has recently been refurbished and now provides an accessible shower. There is also a fitted kitchen, laundry room, conservatory and outside patio area with sensory garden. Service users rooms have been decorated to a good standard and are personalised with their own belongings, family photographs, television, music system, hanging décor and decorative posters. The home provides two areas used primarily as living space. Some of the communal areas will need redecoration in the near future. It is recommended that some of the communal spaces including the lounge and ground floor hallway be redecorated. The home was clean and tidy on the day of inspection. There are adequate provisions for infection control. All personal care is provided in the privacy of service user’s rooms and staff were observed knocking on bedroom doors prior to entering. The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff are experienced and provide a good standard of care. Staffing level is adequate in order to meet service users’ needs. Mandatory training updates for the staff is required. Staff receive appropriate support and supervision. Staff recruitment file did not contain all the information outlined in schedule 2, Care Homes Regulations 2001. EVIDENCE: Duty rotas are maintained appropriately. On the day of the inspection, the home was staffed with five staff (including the manager) during the day, three staff during the afternoon, two waking staff at night, plus a member of staff who cleans the home three hours a day, five days a week. The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 22 Staff spoken with confirmed that they had received appropriate support and supervision. Staff file evidenced that frequency of supervision varied but were overall regular. Staff meeting are also provided regularly. Observation of care provided throughout the inspection process showed that the staff team are caring and demonstrated rapport with the service users. Four staff recruitment files were sampled and these had some of the information required by schedule 2, Care Homes Regulations 2001. The recruitment files did not evidence the staff member’s start date at the home. Two staff files had no written references or application form. Newly recruited staff member received a detailed induction training comprising of some mandatory training, learning how to interact with service users, role plays, and personal intervention training (PIT). Staff training file was viewed and there is evidence that the staff team are undergoing a programme of training updates throughout the year. Training topics included Induction, Food Hygiene, Manual Handling, Emergency First Aid, Health & Safety, National Vocational Qualification (NVQ) in Care and Total Communication. The training file evidenced that some staff mandatory training are in need of updating. It is required that staff are provided with mandatory training refresher. The Pre-Inspection Questionnaire provided stated that five care staff from seventeen have completed NVQ 2 or above. It is recommended that all staff are provided with Protection of Vulnerable Adult training and further increase the level of NVQ trained staff. There are two staff vacancies at present. The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42, 43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is managed well. There is a relaxed and open atmosphere within the home. Appropriate actions have been taken to promote the health and safety of staff and service users. EVIDENCE: The acting manager is Michael Rhodes. Michael has worked in care for a number of years. He previously managed a service providing care for young adults with learning disabilities, therefore has the skills and experience of all abilities and needs. The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 24 Michael has recently come into post and is in the process of applying to the Commission to be registered. He has identified areas for improvement such as improving care plans, activity structure, and communal area upgrade. Staff spoken with confirmed that they feel supported and reassured about working at Old Police House. Michael is supported by five support workers (SW). Staff spoken with confirmed that the manager was approachable and that they would be able to raise any concerns. The home has appropriate policies and procedures in place to safeguard vulnerable service users. All records relating to service users are stored securely in accordance with the Data Protection Act 1998. The home has a current Employers Liability insurance. The home operates a comprehensive system of health and safety audits. Fire safety records were examined. Fire equipment had been serviced and tested as required. However, the fire risk assessment is in need of updating. The Portable Appliances Test (PAT), Electrical Wiring Certificates, Lifting Operations, Lifting Equipment Regulation (LOLER) and Legionella survey have been appropriately maintained. Accident and Incident log was sampled and the last entry was April 2004. The manager informed the inspector some examples of quality assurance monitoring. These are offered through monthly visits (regulation 26), staff meeting, service audits and annual review. The inspector saw records of daily fridge and freezer temperatures. These were found to be within safe range. Food probe records were seen and were maintained within appropriate range. The home has a Hazard Analysis Critical Control policy in place and cleaning schedules were also seen. Safeguards are in place for good food hygiene safety. The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 25 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 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 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 3 X 3 3 3 3 3 3 3 The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 26 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 YA35 Regulation 13 (5) 18 (a) (c) Requirement It is required that mandatory training updates are provided for all staff. Timescale for action 15/05/07 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 YA5 YA6 Good Practice Recommendations It is recommended that service users contracts (terms and condition of residency) be dated. It is recommended that the service user care plans are updated, reviewed and all out of date information archived. Carried forward from the last inspection. It is recommended as good practice that two staff signatures confirm all financial transactions. It is recommended that two staff signatures support all hand transcribed entries on the Medication Administration Record. It is recommended that the Complaint procedure make clear to the reader that statutory agencies can be contacted at any stage of the Complaint procedure. DS0000030144.V325101.R01.S.doc Version 5.2 Page 27 3. 4. 5. YA10 YA20 YA22 The Old Police House 6. 7. YA23 YA28 8. YA35 It is recommended that all staff receive POVA training update as good practice. It is recommended that some of the communal spaces including the lounge and ground floor hallway be redecorated. Carried forward from the last inspection. It is recommended that the frequency of moving and handling training be reviewed. Carried forward from the last inspection. The Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Old Police House DS0000030144.V325101.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!