Inspection on 08/05/08 for Vale Road (15a)

This inspection was carried out on 8th May 2008.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Vale Road (15a) 05/11/08

Vale Road (15a) 10/05/07

Vale Road (15a) 19/10/05

Vale Road (15a) 27/07/04

Vale Road (15a) 10/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Vale Road (15a) 15a Vale Road Ash Vale Nr Aldershot Hampshire GU12 5HH Lead Inspector Vera Bulbeck Unannounced Inspection 8th May 2008 09:45 Vale Road (15a) DS0000013452.V363060.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 Vale Road (15a) DS0000013452.V363060.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. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vale Road (15a) Address 15a Vale Road Ash Vale Nr Aldershot Hampshire GU12 5HH 01252 334880 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) www.unitedresponse.org.uk United Response Manager post vacant Care Home 5 Category(ies) of Learning disability (0) registration, with number of places Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - (LD) The maximum number of service users to be accommodated is 5. Date of last inspection 10th May 2007 Brief Description of the Service: 15a Vale Road is a purpose built bungalow, which is owned by English Churches Housing and managed by United Response. The home is situated in a quiet residential cul de sac in Ash Vale Village. The home is close to local amenities and the railway station, and there are good road links to the nearby towns of Aldershot, Farnborough and Guildford. The home provides accommodation for five service users with learning disabilities, some of whom have physical disabilities. All service users have their own bedrooms and there are two supported bathrooms available. The home has a communal dining room and lounge and there is easy access to a well-maintained garden. The home has parking for several cars and the homes minibus. Fee levels for 2006/2007 range from £1.286.65 to £1.300.69 per week. The staff on duty was not able to provide an up to date level of fees for 2008/2009. The fees do not cover personal items, hairdressing and holidays. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This unannounced visit formed part of a ‘key’ inspection and was carried out by Vera Bulbeck, Regulation Inspector. The two support staff on duty represented the establishment. The registered manager has resigned from her post and the acting manager was not available. It took into account detailed information provided by the staff on duty and any information that the Commission for Social Care Inspection (CSCI) has received about the service since the last inspection. A tour of the premises took place. On the day of this visit the inspector spoke with the service users, and three staff on-duty. Prior to the inspection, survey forms were sent to the home to pass to service users, their relatives and/or advocates and to staff employed at the home. The home had completed an annual quality assurance assessment (AQAA) and service users’ care plans, training records, menus, health and safety check lists, activity records, policies, procedures, medication records and storage were all sampled on the day of this visit. The Commission would like to thank the service users and staff for their time, assistance and hospitality during this visit. What the service does well: The staff has a good understanding of the service users and their needs. It was noted that staff are able to communicate well with each individual by their knowledge of the service users, expression and listening. The management of the home has met the majority of the requirements from the previous inspection, except one, this requirement needs to be addressed immediately. The staff informed the inspector that management are proactive and want to ensure the home is working towards meeting all the National Minimum Standards for adults. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New admissions to the home would only be admitted following a needs assessment to ensure that the home can meet the service users’ identified needs. EVIDENCE: There were no pre assessments on the files sampled this was because all five individuals living in the home have lived in the home since the home was registered some time ago. The staff confirmed that any potentially new people entering the home would have a pre needs assessment carried out to ensure the home can meet the needs of the service user. The staff on duty explained that full details of any potentially new persons would be undertaken before the person enters the home. The staff member on duty explained the admission procedure and criteria to reflect the principles of admission and assessment appropriate to the home. This should be reflected in the homes statement of purpose. The statement of purpose and service users guide needs updating. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 9 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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users health, personal and social care needs are set out in an individual plan of care, however the care plans need up dating to ensure service users needs are met in accordance with the homes philosophy. Staff supports service users to make decisions and to promote independence where possible. EVIDENCE: Two individuals care plans were sampled and there was evidence that people using the service’ health, personal and social care needs had been identified and assessed. Care notes were detailed to include individual’s daily routines. Service users are not able to be involved with their care plan. The care plans hold all the relevant information; this includes optical, dental and health professional involvement, as well as the G.P. However the care plans need to be more person centred. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 10 The care plans are kept in the office, and staff has access. Individual persons care plans should indicate who are able to hold a key to their bedroom; keys are currently left in the locks of bedroom doors. Details need to be documented in the care plans and should include the reasons for not holding a key. Risk assessments need to be updated and reviews need to be undertaken on all individuals, currently there are no care managers involved with any of the persons living in the home. Staff stated that service users are supported to make decisions affecting their lives in a number of ways. The five persons living in the home have limited communication and staff has the experience to enable service users to make some decisions and choices. Holidays, menu planning and outings are mainly with staff support, and generally by knowing the individual well. Observation by the inspector, staff are respectful to the service users. It was also noted that individuals and staff have a good rapport. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 11 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): 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users have limited opportunities for personal development. They are supported and enabled by staff to maintain and develop appropriate personal and family relationships. The meals served and the menu seen was observed to be are well balanced and varied. EVIDENCE: The daily routines at the home reflect the requirement to promote independence, individual choice and freedom of movement. Service users were unable to confirm if they are able to choose what to do, when they wanted. Observations made by the inspector on the day of the visit were service users had little to do and it was noted for the best part of the day one service user wandered up and down the corridor. Another service user was able to follow the member of staff from room to room in her wheelchair. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 12 According to the activity programme for each individual there is limited opportunities for service users to go out, this is due to the present staffing levels in the home. This also applies to activities within the home and in the local community. As detailed in the AQAA, to demonstrate what the home does well, the manager stated that discovering what people enjoy doing and their preferences are taken into consideration in meeting service users needs. This is by using local community facilities and recognising people as individuals, as well as arranging activities flexibly. This is maintained by supporting people and enabling choice. The home has its own transport and most of the staff team are drivers. However, the three staff on duty informed the inspector they are nervous of driving the mini bus. Since they had a test for driving the vehicle, the vehicle has been changed and is now bigger than the previous mini bus. Therefore service users are not taken out very often. The management of the home needs to consider how they propose to ensure service users are using the community facilities. Also the staffing ratio to drive the vehicle needs to be reviewed. At the time of arrival at the home only one member of staff was on duty in the home with three service users in wheelchairs. Another member of staff had taken one service user to the day centre and because of the low staffing levels; another service user is taken along for the ride. According to the activity programme service users spend a considerable amount of time in the home. One service user is taken to the day centre two afternoons a week and the rest of the time he wanders around the home. Monday to Friday the staff take him out in the mini bus for a ride when they are taking or collecting service users from various activities or shopping. When in the home this particular service user spends time in his bedroom lying on his bed, on top of a bare mattress; the service user had removed all the covers from the bed. The staff also informed the inspector the service user had pulled the chest of drawers off the wall, which had previously been secured. His clothes are currently kept in a locked bathroom. The inspector would advise the management of the home to request a review by a care manager to ensure the service user is appropriately placed. The menu was seen to be varied and well balanced; advice is sought from a local dietician for individual service users, as and when needed. The lunchtime meal was taking place during this visit; the food was presented in an appetising manner. There was a relaxed family atmosphere. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 13 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 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff provides personal care to all the service users, staff support service users where needed, in a respectful and sensitive manner. Healthcare support and assistance was detailed in the care plans. The management and administration of medications needs to be reviewed to ensure service users are safe from harm and abuse. EVIDENCE: During this visit two care plans were sampled and it was seen that all health care needs were incorporated into the care plans. Diary notes evidenced that staff take prompt action to deal with any new health problem that may occur and care plans were specific with information for staff to follow when supporting service users to manage any long-term conditions. Medication is provided mostly in blister packs. The administration of some medications was observed and the medication administration records (MAR) were noted that correction fluid had been used and the inspector informed the staff, MAR sheets are legal documents and must not be defaced. It was also Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 14 noted that a label had been removed from a bottle of lactulose, therefore it was not known, which service user this had been prescribed for. The storage for medication was found to be sufficient, however if one of the service users were placed on a controlled drug at any time, the cupboard would not be suitable for storage. The medication policies and procedures were sampled and it was noted they are kept up to date. The inspector was able to speak to the G.P who confirmed he is very happy with the home and staff stated he pops into the home on a regular basis to check up on service users. The G.P stated he pops into the home unannounced and he has known the service users since they were patients in the hospital when he was also working there. He also stated that he likes the service users to visit the surgery, this can only happen when there are sufficient numbers of staff on duty. Also there are times when service users have hospital appointments and arrangements have to be made around the staffing levels. Staff stated that in an emergency staff would contact the on call person for support or an ambulance. In the AQAA, to demonstrate what the home does well, the manager stated that service users are supported to take their own medication as much as possible. However, two service users have covert medication. This practice needs to be fully discussed with the doctor and must be documented in the service users care plan, and signed by the doctor-giving authorisation. The home needs to obtain a copy of the Pharmaceutical guidelines to ensure that staff are kept up to date with the procedures. During this inspection, all interactions observed between staff and service users were polite and respectful. Staff never entered service user’s private rooms without knocking. All personal care was carried out behind closed doors. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All required systems are in place to ensure that service users receive the care they require. The homes policies and practices protect service users from any harm or abuse and neglect. EVIDENCE: The home has a complaint’s procedure in place that is available to all service users or their relatives and is available in an easy read, picture format if required. No complaints have been made to the home since the last inspection. No complainant has contacted the Commission with information regarding a complaint or allegation made to the service since the last inspection. There has been a safeguarding issue referred to the Multi Agency Safeguarding Team, for investigation. A senior care manager investigated this. As a result no further action was taken. There is a whistle blowing policy in place and the home have a copy of the latest Surrey Multi-Agency Procedure for the Protection of Vulnerable Adults. All staff has received training or updates in the protection of vulnerable adults, this is clearly recorded in the home’s training record. In the AQAA, to demonstrate what the home does well, the manager stated that it is difficult to gauge if the individual service user understands the complaints procedure due to the severity of their learning disabilities. The Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 16 management is exploring a more appropriate way of conveying this information. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 17 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, 27 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. The home was found to be clean and hygienic. However, there are areas in the home that require attention. EVIDENCE: 15a Vale Road is set in a semi rural area close to local amenities and the town centre. The home consists of single bedrooms; there is a spacious lounge, separate dining area and kitchen. There are two bathrooms and separate toilets. The garden is well maintained and in good weather is used frequently. The home was toured during this visit. The furniture and furnishings were seen to be of a good quality. Bedrooms were personalised to the individual service user’s wishes, apart from one bedroom, which was bare. The chest of drawers had been pulled off the wall and the bed was stripped of bedclothes. The inspector saw the service user laying directly on the mattress, with some bedclothes on the floor. The staff informed the inspector that the service user Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 18 will not have the bed made and destroys anything in the bedroom. As a result the service users clothes are kept in a locked bathroom. The inspector advised the staff to contact care management for a review of the service user to ensure the home is able to meet the service users needs. There were several areas that need attention in the home. The lounge is in need of decoration and there were lots of cobwebs on the ceiling. The dining area was looking very tired and needs some attention. The staff toilet was without a cover on the light. One of the bedroom door handle had been repaired and there was still plaster smeared around the handle. The inspector was informed a service user goes into this particular bedroom and throws items etc out of the window. The management need to look at how this could be improved so that the service user who occupies this bedroom can still have access to his bedroom without another service user entering un invited. The majority of doors had keys in the lock and some the keys were stuck; one particular cupboard stored pipes, which were very hot. This cupboard should be kept locked at all times and the key removed. The COSHH cupboard was found unlocked and had the key in the door, when staff tried to remove the key as the inspector instructed the key was stuck. As a result a locksmith was contacted and he fitted a new lock, at the time of the inspection. The laundry was also unlocked this is because it is a fire door. The cupboards under the sink were broken and on the shelves were cleaning materials. The staff moved the items to the COSHH cupboard until such time the cupboards are repaired. It was also noted in the laundry room the panel on the boiler was in need of repair. There are two bathrooms and each has been fitted with a parker bath, however one has not been connected. Therefore there is only one bathroom in use for the five service users. It was noted in a Regulation 37 notification that a service user had slipped into the well of the bath and as a result had broken her ankle. This service user is reluctant to use the bath now and staff stated they leave the service user in the hoist while they bathe the person so that she feels more secure. In the minutes of a staff meeting held on 03/01/08 it was noted, “ the bath is not suitable for another service user”. Management are advised to consider a shower room, which would be more suitable for some service users. It was also noted in one of the bathrooms that tiles were off the wall, and a bolt is required on the door to indicate when the bathroom is either engaged or vacant, to ensure the service users are treated with privacy and dignity at all times. There was also an empty pot of sudacrem on the shelf, with no name on. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 19 On the day of the visit the home was found to be warm and bright with a homely atmosphere and a good standard of housekeeping apparent. The garden is nicely maintained and has a pleasant patio area where the service users are able to enjoy some good weather. However, the garden has a ramp, which leads to the riverside. The gate was found to be unlocked the padlock was rusty and had not been used for some time. There are two service users who are mobile and able to walk in the garden, and were seen to walk in the garden on the day of the visit. The gate should be locked at all times this is a potential health and safety hazard. The staff also informed the inspector on the Sunday previous to the inspection, a member of staff heard someone calling from the lounge doorway and was confronted by two ambulance persons, who had gained entry from the gate on the riverside. The ambulance had been called to an emergency on the riverside and was unable to get the ambulance to the riverside area. The ambulance persons requested they bring the person through the grounds of the home. The staff agreed for the person to be taken through the garden to the waiting ambulance. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staff training and recruitment programme, which is designed to ensure that service users are supported by competent and qualified staff, was not available. EVIDENCE: The rota was sampled and needs to indicate when the manager is working in the home. The staff rota evidenced that two members of staff are on duty at any time of the day. However, there was only one member of staff on duty when the CSCI inspector arrived, who was preparing the lunch, cooking chicken for the evening meal, hoovering, doing the laundry, serving drinks to the service users and undertaking administering medication. There were three service users in the home at the time, and all were in wheelchairs. The other member of staff had taken a service user to the day centre and had taken another service user along for the ride. The staff cover long 24 hour shifts, on the day of inspection the member of staff on duty at the time of the Inspectors arrival was due to go off duty at 3pm. This member of staff had been working in the home since 7am on the 7th May including doing a sleep over. There is Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 21 one waking night staff and one sleeping in member of staff to cover the nighttime arrangements. Staff recruitment files were not available. Some training records were available. The training records seen need to be kept up to date. The member of staff stated all staff files and training records are held in a locked facility and staff do not have access to the files. In the AQAA the manager stated the staff team are stable and work well together they are confident and competent in their job and are aware of their responsibility and duty of care to the service users. The three staff on duty on the day of the inspection has worked in the home for some considerable time. One member of staff confirmed they had been supplied with a copy of the General Social Care Council (GSCC) code of conduct and practice. The members of staff on duty confirmed induction is in line with the new, mandatory Skills for Care common induction standards and the inspector was advised that staff are supervised until they have completed their induction. The inspector was also informed by the staff on duty that staff are booked on additional training and updates as the courses become available. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management arrangements in the home needs to improve, more time is needed on management duties particuarly health and safety issues. This is to ensure service users are protected from potential harm at all times. EVIDENCE: The registered manager left 15a Vale Road on 25th April 2008, and the manager who is registered for another service is now managing the staff in both homes. The inspector was informed that service users’ views are sought on a regular basis and monthly visits by a representative of the responsible individual take place as required. The Regulation 26 visits need to be expanded to contain Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 23 more information. According to the most recent report dated 20/03/08 states all health and safety checks up to date. According to the AQAA the organisation carry out yearly surveys, which seeks the views of service users, family, friends and other stakeholders in the community (i.e. district nurses etc.) Details of the survey were not available. The staff at the home carries out all necessary health and safety checks. Documentary evidence of routine fire practices and evacuations need to be undertaken on a regular basis. Fire equipment checks, daily checks of fridge and freezer temperatures and some up to date maintenance certificates were seen. However, the Fire risk assessment was dated 22/09/04 and needs to be updated. There is also a need to implement a fire contingency plan and if necessary to seek the advice of the fire officer. The certificate for the testing for Legionella was dated 29/06/06 and needs to be up dated yearly. All cleaning materials must be kept in a locked facility at all times. On the day of the visit the cupboard under the sink in the laundry was broken and unlocked. A member of staff removed the cleaning articles to the COSHH cupboard as soon as the lock had been replaced on the COSHH cupboard. All staff needs to undertake a refresher-training course on COSHH regulations to ensure the health and safety of service users. It was also noted that a number of recorded accidents were seen in a folder these documents need to be filed in the appropriate persons file to comply with the data protection data. A number of policies and procedures need to be updated with a date of the next review. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 2 X 2 1 X Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA7 Regulation 12(1)(2)(3) 13(4) Requirement Risk assessments must be reviewed and/or introduced to ensure they include all aspects of daily living including where restrictions of choice, independence, access, open bedroom doors and access to toiletries have been introduced. This will ensure that the rights and independence of service users have been taken into account. The person completing them must date and sign the risk assessment. (Timescale 27/08/07 not met). Service users need to spend more time in the community. Service users require stimulation. The needs of a service user to be reviewed by care management. Staff require training and covert medication needs to be discussed with the doctor and recorded appropriately. Some areas of the environment needs up DS0000013452.V363060.R01.S.doc Timescale for action 06/06/08 2. YA13 YA14 16(2) 06/06/08 3. 4. YA18 YA20 14(2) 13(2) 20/06/08 13/06/08 5. YA24 23(1)(2) 20/06/08 Vale Road (15a) Version 5.2 Page 26 grading, and decorating. 6. YA27 23(2) A review of the bathrooms needs to take place including appropriate locks needs to be fitted. The staffing levels must be increased to ensure service users are safe at all times. All staff must have regular up dates to training including mandatory training. Management duties need to be reviewed and to be indicated on the rota when working. The management to produce a quality audit for the home on a regular basis and should be available for inspection purposes. The Regulation 26 report needs to be expanded, to ensure adequate monitoring takes place. Record keeping needs to improve to ensure appropriate records are maintained. All health and safety measures must be in place to ensure the service users are safe at all times. This includes Fire safety and COSHH Regulations. 13/06/08 7. 8. 9. YA32 YA35 YA37 18(1) 18(1) 8(1) 12/05/08 20/06/08 13/06/08 10. YA39 24(1) 20/06/08 11. YA39 26(4)(5) 27/06/08 12. YA41 17(1) Sch 3 17(2)Sch 4 13(2)(4) 23(4) 06/06/08 13. YA42 06/06/08 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 YA13 YA16 Vale Road (15a) Good Practice Recommendations The management should review the present arrangements regarding driving the minibus. DS0000013452.V363060.R01.S.doc Version 5.2 Page 27 2. 3. YA1 YA20 Service users must be able to access the local community and receive appropriate activities. The Statement of Purpose and Service Users Guide need up dating. Management to ensure a copy of the Royal Pharmaceutical Guidelines are kept in the home for reference. Vale Road (15a) DS0000013452.V363060.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Vale Road (15a) DS0000013452.V363060.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. 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