Inspection on 05/07/05 for Thistle Close (24, 30 & 33)

This inspection was carried out on 5th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Thistle Close (24, 30 & 33) 24/10/06

Thistle Close (24, 30 & 33) 11/01/06

Thistle Close (24, 30 & 33) 03/02/05

Thistle Close (24, 30 & 33) 21/06/04

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOME ADULTS 18-65 24, 30 and 33 Thistle Close St Peter The Great, Worcester, WR5 3DP Lead Inspector Christina Lavelle Announced 5 July 2005 13.30 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. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 24, 30 & 33 Thistle Close, Address 24, 30 & 33 Thistle Close St Peter The Great Worcester, WR5 3DP 01905 611147 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) Scope Mr A J Deakin Care Home 6 Category(ies) of Physical Disability - 6 registration, with number of places 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: In addition to the categories of registration described on the previous page of this report the following conditions of registration apply to this service : (1) The home may accommodate no more than 1 resident in 24 Thistle Close; 3 residents at 30 Thistle Close and 2 residents in 33 Thistle Close. (2) The home is primarily for people with physical disabilities but may also accommodate people with associated disabilities. (3) The home can accommodate one named person who is over 65 years with a physical disability. Date of last inspection 3 February 2005 Brief Description of the Service: Thistle Close is run by SCOPE and is part of a scheme called 1st Key Worcestershire and was opened in 1993. The properties are owned by a Housing Association which are leased to the service provider. The home consists of three bungalows which are close together in a small cullde-sac. It is on a large modern housing estate, a couple of miles from the centre of Worcester. This allows easy access to the citys leisure and other services and the home also has the use of two adapted vehicles. There are local facilities, such as a large supermarket, shops and pubs nearby. The home can offer personal care to six adults (men and women) with cerebral palsy and/or similar pysical disabilities. Service users may also have a linked disability. The main aim is to support the people living there to empower them to live an independent life and to be part of the local community. One of the bungalows is for three service users, one is for two and the other just one person. Single bedrooms are provided and each bungalow has a kitchen/dining room and sitting room. None of the bedrooms have en-suite facilities and assisted showers and bathrooms are available. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine announced inspection took place over five and a half hours on a Tuesday afternoon in the summer. The main aim was to obtain an overview of the service provided and to check if the home was meeting its stated purpose. Comment cards had been sent to the home for service users and their relatives and/or visitors before the inspection asking for their views of the home. Questionnaires were also sent for staff inviting comments about their experience of working in the home. Also for staff to show the training they had done and whether they felt other aspects of the service were good or could be better. The feedback received is referred to in this report. Time was spent talking with the manager and some service users. A number of relevant records were checked in respect of the care of service users, staff, the premises and to aspects of health and safety in the home. The bungalows were looked at. Reports made on behalf of SCOPE following required monthly visits to the home gave further information about the service. Also of action to be taken to deal with any matters that had been picked up during these visits. What the service does well: Thistle Close provides ordinary housing for service users which helps the home fit in better with the local community. The home was purpose built for people with physical disabilities and so there are ramps, wide paths and doorways for easier access to wheelchair users. The bungalows are homely and comfortable overall and the location of the home is convenient. The home’s vehicles allow service users to be able to use services and facilities in the wider community. There was a relaxed atmosphere in the home and staff were friendly and seemed to get on well with service users. Each service user has a keyworker from the staff team, which makes the care and support given more personal. Service users are encouraged to lead an independent lifestyle as far as they can and wish to. Staff support them with their personal and health care to ensure their needs are met properly and that any problems are dealt with. New staff have to undertake training that is especially for people that work in care. This should ensure they have a good basis to develop the skills and knowledge needed to do their job properly. All staff have to undertaken all the health and safety training that is necessary to keep the home, service users and the staff team as safe as possible. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: 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. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 7 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 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 8 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 & 4 Information documents are provided to help prospective service users decide if Thistle Close is where they may wish to live and whether the home could meet their care needs. The home had appropriate procedures in place for the assessment and admission of prospective service users’ needs to ensure placements made would be suitable. This process would improve if new service users’ needs, goals and wishes were fully assessed on their admission and during their trial stay. Further if care plans based on these assessments included any agreed restrictions on service users’ choice and freedom. EVIDENCE: There is a statement of purpose and service users’ guide for the home, which were found to be substantially satisfactory in previous inspections. A contract is also available, although it was not confirmed in this inspection that each service user had agreed this document (and signed it if possible) and had received a copy in a suitable format, or which had been explained to them. The manager always visits prospective service users to give them information about the home and to assess their needs. Following this a trial stay is arranged at the home with a review meeting held at the end with the service users and relevant other people. Should a decision be made for them to live at the home the contract (called the Service Level Agreement) would then be agreed and signed by the service user and registered manager. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 9 One recently admitted service user’s care records were checked. A Community Care Assessment made by a social worker prior to admission had appropriately been obtained. The manager had also visited them at their previous residence and they had visited Thistle Close before a trial stay at the home was agreed. An initial assessment of most areas of their needs had been available prior to this person’s admission. However they had been staying at the home for nearly two months and staff had yet to complete a detailed care plan. Aspects not covered included the individual’s views and goals and the action needed from staff to ensure some of their specific needs were met. For instance there was limited information relating to moving and handling and of support needed to manage their finances. The manager also said it had been agreed prior to admission that staff would have to help this person to bed by a certain time due to staff cover. This was not included in their plan however and the service user was unhappy about having to go to bed before they sometimes wanted to. Development of care planning and assessment is needed so that the home is able to show it can suitably meet new service users’ needs and aspirations and that restrictions on their choice had been agreed. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 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 & 9 An assessment and care planning system is in place to identify service users’ needs and to help staff know better how to support them and meet the needs. More detailed assessments and plans would ensure staff are fully aware of all their needs in order to provide consistent support and also a more person centred planning approach would ensure the support provided is based on service users’ views of their needs, their wishes and life goals. Risk assessments are undertaken to safeguard service users by minimising risks and to allow them to take responsible risks to promote independence. EVIDENCE: The sample of service users’ care records checked included background details and history, care plans and risk assessments. Other helpful information about service users’ care and progress, health etc. was recorded by staff in daily reports and on significant event sheets. Care plans had been drawn up that covered most relevant aspects of service users’ care needs. Plans were reviewed at least six monthly as the Standards specify. One plan seen had been updated recently although the plan was not very detailed and the financial assessment had not been completed. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 11 The service users’ guide describes a person centred approach to care planning. Although plans had evidence of some input from service users this process was not formalised. The manager confirmed that service users are involved in drawing up their own plans and in reviews of their care and plans. However the introduction of a Person Centred Planning system should be considered as part of the further development of assessment and care planning. Risk assessments had been carried out (such as moving and handling and a bathing policy) to guide staff action and to ensure service users’ safety. Appropriate attention was also paid to individuals with communication difficulties. Pictures were used to help one person choose their shopping and there were communication guidelines for another person. The home operates a keyworker system, which can help to individualise care. Support staff are allocated to particular service users and are more involved in their care planning, personal care and support. Unfortunately due to staff sickness one service user had not been able to have this input. Consideration should be given to allocating another staff member as keyworker until they return to work. The manager was aware of the value of advocacy for service users. Although a local advocacy scheme had recently stopped providing an individual service other options were being looked at. Keyworkers and a Lifestyles scheme already facilitated activities and supported some service users in this respect. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 14 & 15 Service users were enabled to seek and take up opportunities to promote their participation in the wider community. Also so they were able to lead more interesting and fulfilled lives, both socially and in respect of their personal development. This could be increased if there was more staff time available to support them on an individual basis more often. Service users are supported to maintain links with their families and friends. EVIDENCE: Weekly activities timetables had been drawn up for service users. One programme included specific time provided by staff to facilitate these activities as well as an outside person from Lifestyles employed by the service users. Some service users were enrolled on college courses to develop their life skills. One service users attended a college course for two and a half days a week and said they would now be bored stiff as the college had broken up for summer. They were hoping to enrol on another course to keep occupied during this time. The manager said that college placements were not part of this person’s care package. Their local authority had been approached for 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 13 extra funding but had refused this. Some staff and service users commented there were not always enough staff to support 1 to 1 activities in the community. Staffing levels should be reviewed and levels increased if they are adversely affecting service users’ opportunities for leisure and personal development and their inclusion in the community. Service users should also be consulted about this. Service users follow their own interests and social activities, such as watching television, going to the local pub and those able to go out in their wheelchairs. The home has access to two vehicles and one service user also had their own car that staff drive for them. One person was going on a holiday they had chosen, although staff are not involved in supporting them on holidays. Families and visitors to the homes were made welcome and some service users had their own telephones so they could contact them directly. Families are always invited to attend service users’ annual care reviews. Although Standard 17 regarding food provision was not fully assessed it was confirmed that records are kept of meals provided as is required. Service users said they help to choose menus and do the shopping. One person can make their own drinks and snacks and is enabled to do so. All the service users (except one) commented they like the food provided. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 & 19 Arrangements were in place to ensure the personal and health care needs of service users were appropriately meet. This included obtaining the input and support of relevant health care and other professionals whenever necessary. EVIDENCE: Service users confirmed staff provided the personal care and support they need. Whilst they are afforded some flexibility in their daily routines and lives clearly this is to some extent affected by staff availability when they are dependent on staff to help them get up, go to bed and out in the community. Plans had been drawn up to ensure that particular health care issues were monitored and dealt with properly, such as epilepsy and wound dressings. Care records showed that annual health care checks were arranged with or on behalf of service users. Also that various healthcare professions provided appropriate input and support such as a psychiatrist and community nurse. An Occupational Therapist had visited recently to assess one person’s needs. However there had been a delay in providing the equipment recommended which was affecting them being able to go out. The manager agreed to chase this up again and to contact their social worker to inform them. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 15 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 An appropriate framework of policies and procedures were in place to deal with complaints and to help protect service users. Also to ensure staff were made aware of the indicators of abuse and their responsibility to report any suspicion or evidence of abuse or neglect. EVIDENCE: The home provides a suitable complaints procedure that can be made available in a format that some service users would be able to understand better. SCOPE also employs a Complaints Officer who can be contacted to deal with complaints internally. One service user confirmed they were aware of and would know how to use this complaints procedure. The Commission had not received any complaints about the home since the last two inspections of the home. It was previously confirmed that SCOPE provide policies and procedures for the protection of vulnerable adults, including whistle blowing. The organisation has a designated Adult Protection Advisor and the home also has a copy of the local multi-agency procedures for the Protection of Vulnerable Adults. The manager confirmed that all staff had received in-house instruction to ensure they are aware of these policies and procedures as well as their responsibility to safeguard service users from abuse and neglect. Although the home’s practices regarding service users’ money and financial affairs were not fully reviewed one service users said that they manage their own finances and have a secure place to store their money. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 16 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 Thistle Close provides ordinary housing and the environment overall is homely and comfortable. Although the bungalows were purpose built, and have been adapted and equipped to meet service users’ special needs, the space available in two bedrooms is rather restrictive for wheelchair users. Whilst there are arrangements in place to promote safety and maintain and/or upgrade the premises two of the bungalows would benefit from some areas being redecorated and/or refurbished and refitted. EVIDENCE: The bungalows in Thistle Close are in keeping with the local community and so provide a normal living environment for service users. They are owned by Bromford Corinthia Housing who are responsible for any structural work. This organisation leases the properties to SCOPE who must maintain the internal decoration and furnishings/fittings. One bedroom has been refurbished and decorated recently (the occupant having chosen the colour and furniture) and looked very nice. However some areas clearly needed some work. In particular Bungalow 30 has carpeting on 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 17 the bottom of the corridor walls to prevent damage from wheelchairs. This was rather frayed on the corners and the paintwork was damaged. Bungalow 33 was rather bare of furniture, in need of decoration and the carpeting was shabby and stained. The kitchen would also benefit from being upgraded. Whilst it is acknowledged the occupants were having a trial stay at the home the impression obtained overall of this bungalow was rather poor. The manager said that damage and staining had occurred during the trial stay and the sitting area had been left unfurnished until the home and service users clarified what would be needed. The garden areas had been cleared since the last inspection and a patio was due to be laid. It was good that service users had chosen the plants. Each bungalow had sufficient and suitable communal space and toilets and assisted showers and or bath facilities. Bungalow 30 has a separate laundry room with a washing machine and the other bungalows have suitable laundry facilities. Bedrooms are all single and were well personalised. It was apparent however that the space available in the bedrooms of two service users was restrictive due to them being wheelchair users. One person had to back out of their room as there is not enough space to turn their wheelchair and there was no room for a bedside cabinet. The wash hand basin in one bedroom was too high for the service user to use comfortably. The manager said that advice had been taken from an occupational therapist about this. Whilst the difficulty in increasing the size of these rooms is acknowledged the limited space should be taken into consideration when service users are considered for admission in these rooms in future. The pathways around the bungalows (and doors) are wide and there are ramps to enable wheelchair access. There were also hoists and overhead tracking for easier access to shower facilities and assisted baths and an alarm call system is fitted throughout the home. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 18 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 An adequate staffing level is maintained to cover the home, although this does not always ensure service users had enough staff time to support them with leisure and other activities requiring individual staff support. The home and service users will also benefit when there is a more consistent staffing input. Overall staff had received suitable training to do their jobs properly and work safely. However the uptake of staff to undertake NQ training needs to continue so that a sufficient number of the team achieve this qualification. For the protection of service users from unsuitable people working at the home one aspect of the home’s recruitment procedures must always be followed. EVIDENCE: It was confirmed there was an adequate number of staff to ensure service users’ personal care needs are met and the home is safe. However two staff were currently on long term sick leave and so relief and agency staff were being deployed at the home extensively. Whilst the home was recruiting new staff, and tries to use the same agency staff, this can affect the consistency of care when staff do not know service users’ needs and the home as well. The manager expected this situation would be resolved before too long. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 19 Seven of the nine support workers returned their questionnaires. About half of them indicated they felt there was insufficient staff time for service users; in particular to give them enough support to participate in social and leisure activities. As care staff take responsibility for the cleaning and cooking this too affected time available to talk and spend individual time with service users. Staffing levels should b reviewed in consultation with staff and service users to ensure service users’ lives are not restricted due to lack of staff time. It was previously confirmed in inspections that SCOPE operate thorough recruitment procedures. One staff record of a recently appointed support worker was checked and a CRB/POVA check and two written references had appropriately been taken up. However the references received were from an ex-colleague and a personal friend and did not include the person’s last employer as is now required. SCOPE operate an induction programme for new staff that is based on relevant specifications. Most staff had completed core health and safety training topics and received instruction relating to adult protection. Those staff responsible for administering medicines had attended a safe handling of medicines course. Three staff had obtained an NVQ qualification and two were soon to complete it. The programme of NVQ training should continue so that 50 of the team achieved this qualification this year. The NVQ assessors on the team should assist this process. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 20 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, 39 & 42 Systems were in place to promote effective management of the home and the lines of accountability are clear. When the manager achieves an NVQ level 4 qualification this should also benefit the home. There should be better oversight of the service and its development when the recently introduced Quality Assurance (QA) system is fully implemented. Although health and safety matters are very wide ranging (not all areas were reviewed) it appeared overall that staff and service users are safeguarded from risks by the provision of a safe environment and working practices. Their protection will be improved when the fire alarm system is always tested weekly. EVIDENCE: The manager is the Community Service Manager with responsibility for three 1st Key homes and has an office base at Unit 3 Lowesmoor Wharf, Lowesmoor, Worcester WR1 2RS. A senior support worker supports a team leader in the 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 21 day-to-day management of the service. The manager is now about half way through NVQ4, which is the qualification expected of care home managers. Although Standard 39 was not fully assessed the manager confirmed that the processes of auditing aspects of the service had been reviewed and would include quarterly health and safety and care audits with reports made. Further that an annual service user survey had been introduced as part of the quality assurance system. The home has a moving and handling trainer on the staff team and there is input from the SCOPE health and safety team. Most staff had undertaken the mandatory health and safety training topics. The fire log was checked and there were gaps in the recording of the weekly checks required of the fire alarm system. This was brought to the manager’s attention and must be addressed. A fire maintenance engineer services the system and equipment as expected and a drill has been arranged recently. The staff who had all participated in drills were listed to ensure they all participate in a drill at least once a year as required. A service agreement for the gas installation was seen. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 22 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 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 3 3 3 3 x Standard No 11 12 13 14 15 16 17 2 2 x 3 3 x x Standard No 31 32 33 34 35 36 Score x 2 2 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 24, 30 and 33 Thistle Close Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 2 x E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA 2&7 Regulation 13 Requirement Restrictions on choice must be developed in care plans. (This requirement was made following the last inspection and is brought forward with an extended timescale.) The shortfalls in the quality of the accommodation (as described on the Premises section of this report) must be addressed. The work needed must be included in the homes planned renewal programme, a copy of which to be submitted to the CSCI with their response to this report.. References taken up for new staff must include the applicants last employer and/or a previuos employer. Timescale for action by 31/08/05 2. YA 24 23 by 31/12/05 3. YA 34 19 Immediate and henceforth 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 YA 6 Good Practice Recommendations Further developmetn of assessment and care planning is E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 24 24, 30 and 33 Thistle Close 2. 3. YA 7 YA 11, 12 & 13 needed to ensure that all aspects of service users needs and personal goals are reflected in their plans. A more Person Centred approach to assessment care planning should be introduced. Staffing levels should be monitored and reviewed to ensure service users are receiving sufficient individual staff time. This should also enable them to take up opportunities and participate in leisure and other activities in the community which require staff support. The review should involve consulting with service users and staff. 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Hereford Area Office, 178 Widemarsh Street, Hereford HR4 9HN 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 24, 30 and 33 Thistle Close E52 S18693 Thistle Close V 229275 050705 Stage 4.doc Version 1.30 Page 26 - 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!