Inspection on 02/04/07 for Vaughan House

This inspection was carried out on 2nd April 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Vaughan House 15/01/08

Vaughan House 09/06/06

Vaughan House 18/10/05

Vaughan House 22/06/05

Vaughan House 15/03/05

Vaughan House 09/12/04

Vaughan House 03/03/04

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 Vaughan House 21 Studley Road Luton LU3 1BB Lead Inspector Mrs Louise Trainor Unannounced Inspection 2nd April 2007 14:15 Vaughan House DS0000014979.V334000.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 Vaughan House DS0000014979.V334000.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. Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vaughan House Address 21 Studley Road Luton LU3 1BB 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) 01582 734812 01582 415196 Vaughan.house@craegmoor.co.uk info@craegmoor.co.uk Parkcare Homes Limited Vacant Care Home 10 Category(ies) of Learning disability (10), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 18-65 years. Maximum number of service users - 10. The category MD is for one service user only named in correspondence dated 24th June 2005. No further service users in the category MD are to be admitted to the home. 19th October 2006 Date of last inspection Brief Description of the Service: Vaughan House provides accommodation for ten male adults with learning disabilities and currently all the residents are males. Craegmoor Healthcare owns the home. The home is situated in a pleasant residential area of Luton at a short distance from the town centre, which can be accessed on foot if necessary. Accessible facilities in the centre included a cinema, swimming pool, bowling alley and league football team. The building has been converted from a domestic dwelling to provide ten single bedrooms, with en-suite shower facilities to five of these and four with en-suite toilets. The remainder have wash hand basins. The bedrooms are located on all three floors of the house. Combined bath and toilet facilities are provided on the first and second floors and there is a communal toilet on the ground floor. Also on the ground floor there are a lounge, kitchen with dining area and an office. A laundry area had recently been added to the side of the building. Two further staff rooms are provided on the top floor. There is an enclosed rear garden, which is mainly laid to grass, and at the front of the house there is a paved parking space for three or four vehicles. The fees for this service presently range from £415.22 to £1633.66 per week. Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection for this year for this home, and it was carried out on the 2nd of April 2007 between 14.15 hours and 19:30 hours by Regulatory Inspector Louise Trainor. Both the newly appointed Manager and deputy were present throughout the inspection. There are presently ten service users living at Vaughan House, most of who were seen during this visit. Two service users were interviewed in more depth and two service user files were inspected. Other documentation viewed during this inspection included; staff personnel files, supervision records, Medication Administration Records, Accident and incident records, service users financial records, and other service user information documents including the Service User Guide and the Complaints Policy. Staff were observed interacting with service users, however none were individually interviewed on this occasion. A full tour of the premises took place in order to assess the progress made regarding the environment. This had been one of the main areas of concern from the previous inspection. All of the service users had returned ‘Have your say about…..’ surveys to the Commission for Social Care Inspection (CSCI), and these responses have also influenced the content of this report. The inspector would like to thank everyone involved for their assistance and support during this inspection. What the service does well: The home has a Statement of Purpose that has been reviewed and updated. All service users had been issued with a Service Users Guide that had been simply written and included pictorial symbols. The service users had been helped to read and understand these documents and had signed to confirm their receipt. There were care plans in place that had been well written, to include personal preferences and prescriptive detail, so that service users needs would be met in a way they prefer and with continuity. Service user meetings are held at least once a month and service users are encouraged to put forward their ideas and opinions regarding all aspects of life in this home, including activities and menus. Each service user has numerous risk assessments in place relating to all sorts of health and safety issues. Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 6 The manager discussed plans for a summer- house that will double up, as an activity workshop with a potters’ wheel, an organ and a flower press, but at present space within the home is rather limited. The new manager has just introduced a new four- week menu plan, which includes all the service users favourites but has incorporated more fresh vegetable rather than chips and beans. There is always a light alternative available. She is also encouraging more participation in the kitchen from the service user. There is a satisfactory complaints policy in place that is summarised in the service user guide and accessible by all service users. There had been no formal complaints to the home since the last inspection. Situations were appropriately reported to CSCI as part of regulation 37 and there was evidence that, when necessary, staff had worked with the Local Authority Adult Protection team. Staff were aware of the Protection of Vulnerable Adults procedures and had attended training and updates. Information was available for staff and service users about ‘Whistle blowing’ procedures. What has improved since the last inspection? What they could do better: There is a range of activities available for service users, however since the recent closure of the Woodstock day centre not all service users appear to be benefiting from structured activities. Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 7 The manager discussed plans for a summer- house that will double up, as an activity workshop with a potters’ wheel, an organ and a flower press, but at present space within the home is rather limited. There is a medication policy in place, however minor errors indicate that all staff are not always adhering to it so service users may not be protected at all times. The environmental changes and improvements are now in the final stages, and work so far has enhanced the home making it safe and more homely. The recruitment process is sufficient and is being closely adhered to, however the training and supervision of staff is presently in need of improvement to ensure the people who use this service have their needs are fully met at all times. 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. Vaughan House DS0000014979.V334000.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 Vaughan House DS0000014979.V334000.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, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This service has a detailed Service User Guide and Statement of Purpose. The Service User Guide is produced in an easy to read format ensuring that service users and their families know that the home will meet their needs. EVIDENCE: The home has a Statement of Purpose that has been reviewed and updated. All service users had been issued with a Service Users Guide that had been simply written and included pictorial symbols. The service users had been helped to read and understand these documents and had signed to confirm their receipt. Since the last inspection a new Manager has been appointed to the home, and no new service users had been admitted to the home since this time, or in fact since the previous inspection. Therefore as the present service user files had been inspected to confirm pre admission assessments were evidenced, these particular documents were not re inspected during this visit. Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 10 Individual contracts and terms and conditions were held on individual service users files. Vaughan House DS0000014979.V334000.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, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were care plans in place that had been well written, to include personal preferences and prescriptive detail, so that service users needs would be met in a way they prefer and with continuity. EVIDENCE: Service users files that were seen contained, clearly detailed care plans and included personal likes and dislikes, suggesting that these factors are all considered when care is delivered. These care plans were being reviewed on a monthly basis to address changes in needs. In addition to these care plans Annual reviews are carried out involving other professional disciplines and these are clearly documented. Service users have recently completed a form that indicates their preference in gender of the carer that delivers their care. Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 12 One service user file that was seen, contained plans relating to varying aspects of his life, and ranged from personal hygiene and medication to road safety and finances. These plans gave a clear account of the level of care required. One particular area of development that is presently being addressed is his ability to take his girlfriend out for a meal. At the moment the staff also attend, but sit in another part of the restaurant so that they can intervene if the necessity arises. This particular service user proudly told the inspector about this development. He said. “I’m independent you know, I also go out and get my haircut on my own”. Service user meetings are held at least once a month and service users are encouraged to put forward their ideas and opinions regarding all aspects of life in this home, including activities and menus. With the recent closure of the Woodstock Day Centre, service users are being more actively encouraged to make decisions about how they spend their time both in the home and in the local community. Each service user has numerous risk assessments in place relating to all sorts of health and safety issues. One service user’s file contained a risk assessment to allow him to make hot drinks in his room. He now has a kettle in place and has an identified money management plan which allows him to purchase his own coffee and tea. He confidently made the inspector a cup of coffee during the course of this visit, thus demonstrating his level of independence. Vaughan House DS0000014979.V334000.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 adequate. This judgement has been made using available evidence including a visit to this service. There is a range of activities available for service users, however since the recent closure of the Woodstock day centre not all service users appear to be benefiting from structured activities. EVIDENCE: There is an activities programme in place. This includes a wide variety of choices such as; swimming, sewing, arts and crafts, working with numbers, quizzes and days out exploring places of interest. However at present some areas of the programme are not fully functional as the home is waiting for four new staff to start, which will enable things such as swimming to happen more frequently. The home has increased its’ staff numbers since the closure of the Woodstock day centre. The manager discussed plans for a summer- house that will double up, as an activity workshop with a potters’ wheel, an organ and a flower press, but at present space within the home is rather limited. Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 14 Some of the service users attend day centres around the local area such as Bramingham and the Townsend centre, however one service user said. I’ m in during the day’, and gave the impression he was sometimes a little bored. There are a variety of evening clubs available to the service users, and community events such as festivals and fetes feature on the activity programme. Weather permitting parties and bar-b-ques are arranged and service users are encouraged to invite friends and families. Service users from another home are also regularly invited to events with Vaughan House, and two of the service users talked about their girlfriends who lived at the other home. Three different holidays have been booked for June, to accommodate different service users preferences and needs. Six service users are going to Spain accompanied by three staff, three service users who cannot fly are going to Euro Disney via the Euro Tunnel with two staff, and one is going to Devon with his parents and one member of staff. One service user told the inspector how much he liked living at this home. He said. “I quite enjoy living here, I’m in during the day, but always go to club on a Wednesday evening. I do my washing and cleaning and I sometimes help with the cooking. We have a really nice menu now, my favourite is chicken curry or corned beef hash. I’m allowed to go to bed when I want and I always get up early. The staff are very nice and recently I have a new Key Worker and that feels ok too, he’s very helpful. I like sports and Bond films and go home once a fortnight, and have my favourite kippers for breakfast.” The new manager has just introduced a new four- week menu plan, which includes all the service users favourites but has incorporated more fresh vegetable rather than chips and beans. There is always a light alternative available. She is also encouraging more participation in the kitchen from the service user. Observations of staff / service users interactions indicated a relaxed atmosphere of companionship with a mutual respect. All service users appeared content whilst going about their daily tasks whether independently or with support from the staff team. All service users have individual development plans and goals, for example some are being given the opportunity of having facilities in their rooms to make hot drinks. All are being offered front door keys to enhance their independence. Vaughan House DS0000014979.V334000.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 adequate. This judgement has been made using available evidence including a visit to this service. There is a medication policy in place, however minor errors indicate that all staff are not always adhering to it so service users may not be protected at all times. EVIDENCE: All service users had their own medication file. These contained a personal medication profile, to include allergies, a photograph and a letter signed and agreed by the GP relating to homely remedies. There is a sample signature sheet displayed on the office wall. None of the service users in this home are presently capable of self-medicating all are supervised by the staff. All the medication records were checked and with the exception of one dose of Paracetamol, all had been recorded appropriately. The controlled drug book had been filled in clearly with and included clear entries where one service user took his medication to the day centre. Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 16 Returns were clearly documented however there was a minor discrepancy noted one of the listed returns. Service users are encouraged to make choices about all aspects of their lives. They are involved in the care planning and it is hoped this process will be enhanced further by the introduction of Person Centred Planning. Recently service users have completed questionnaires identifying the gender of carer they would prefer to assist them. Documentation indicated that service users are encouraged to have both dental and optical checks. One service user had just returned from the optician on the day of the inspection. A chiropody service is also available when needed or requested by the service users. Vaughan House DS0000014979.V334000.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 complaints policy is sufficient to ensure that service users feel their views are listened to and acted upon in a timely way. EVIDENCE: There is a satisfactory complaints policy in place that is summarised in the service user guide and accessible by all service users. There had been no formal complaints to the home since the last inspection. All the service users have daily spending money kept within the home. Clear records are kept and are audited each month to monitor their accuracy. Four service users’ account records were picked at random by the inspector and checked. All corresponded to the funds remaining, and there were signed and dated receipts present for every transaction that had taken place. Situations were appropriately reported to CSCI as part of regulation 37 and there was evidence that, when necessary, staff had worked with the Local Authority Adult Protection team. Staff were aware of the protection of Vulnerable Adults and had attended training and updates. Information was available for staff and service users about ‘Whistle blowing’ procedures. Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environmental changes and improvements are now in the final stages, and work so far has enhanced the home making it safe and more homely. EVIDENCE: The inspector was accompanied on a full tour of the building, by the new home manager, during this inspection, to look at the progress of the refurbishment. Changes to the kitchen/ dining area are now complete, and although small, provided a clean and safe area for service users to prepare and eat meals. Handrails have now been fixed to the stairs situated between the kitchen and dining area. The ceiling has been repaired and the kitchen refurbished with new equipment. An ice cream maker and a frothy coffee maker were amongst some of the new gadgets in the kitchen. Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 19 Most of the bedrooms have been decorated and are furnished to individuals taste. One service user has a particular interest in birds and clocks, and this was very evident from the pictures and ornaments when you entered his room. Another service user had just got a new recliner chair in his room, and had also bought a kettle so that he can make hot drinks for himself and his guests. This was all part of his personal development plan. Bathing and shower facilities are sufficient, however some minor attention is required to smarten them up. For example a new side panel was required for one bath, and the bathroom cabinets are waiting to be removed, as the manager has decided that it is more appropriate for the service users each to have a toiletries cabinet in their individual rooms. The main area unfinished was the lounge. The manager explained that they are presently waiting for the new floor to be laid. A new convector heater has been installed, which is safer for the service users, as it does not get hot to touch. Pictures of the service users are ready to be framed and put up on the walls, one of the service users had chosen a new clock for the lounge, and new leather suites are ordered, but delivery had been postponed until the flooring is complete. The manager also discussed her plans for a new summer- house in the rear garden area, which will also be used as a workshop for some crafts and activities. Vaughan House DS0000014979.V334000.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): 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. The recruitment process is sufficient and is being closely adhered to, however the training and supervision of staff is presently in need of improvement to ensure the people who use this service have their needs are fully met at all times. EVIDENCE: The new manager is trying to lead the staff in this home in a constructive way that involves some changes. As expected some staff have been resistive to these changes which has resulted in them leaving, however there are four new staff waiting to start and the majority of the team are now supportive of her. Both the manager and her deputy have recently attended a course on Person Centred Planning, which they are presently introducing into the home, and they are both due to attend a Health Action course within the next couple of weeks. Three staff files were picked at random and examined during this inspection. All contained the appropriate documentation including; fully completed application forms, two references (one from the most recent employer), terms Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 21 and conditions of employment clearly signed and dated, various forms of identification and proof of address, Enhanced Criminal Record Bureau (CRB) checks and POVA list checks, passports and job offer letters. Unfortunately evidence of training that had been attended and supervision was very limited. The new manager was already very aware of this and had arranged retraining on all mandatory subjects for all staff from the 24th to the 27th of April 2007. She had also addressed the need for specialist training in Autism, Epilepsy and Promoting Independence, and Mental Health training. She stated that all new staff complete an Induction and Foundation programme, working a three- month probationary period, and during this period work shadowing other staff. Vaughan House DS0000014979.V334000.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, 38, 39, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a new manager and deputy manager in place, and the implementation of new systems is ongoing, however this progress needs to continue to ensure the rights and best interests of people who use this service are promoted and protected. EVIDENCE: There is a new manager and deputy manager that have been in post in this home since early February this year. Both are experienced practitioners that have been working for this company for some time. Both demonstrated how committed they are to improving this home for the people who live here. The manager is introducing gradual changes into the home, such as a new Key Worker plan, encouraging more one to one working on personal development Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 23 skills, during the day when service users had previously been at the Woodstock Day Centre. She has already addressed Quality Assurance through Relative and Service User questionnaires, and in-house auditing, working through an action plan to ensure all areas of care are covered. It is planned that meetings for the people who live in this home, and their families will be held monthly. The inspector looked at minutes from the most recent meeting held on the 02/03/07. This meeting had been used to plan events for the whole of 2007, and these events ranged from Car Boot Sales to sightseeing trips to London and weekend trips to Calais. Ten service users questionnaires were returned to the Commission for Social Care Inspection (CSCI). All were completed by tick boxes, but few had additional comments added, and unfortunately these were not received in time for the inspector to study prior to the inspection. However all service users that the inspector spoke to during this visit were very happy living at Vaughan House. There is a clear focus on the personal development and involvement of service users in every aspect of life in this home. The manager and her deputy have attended a Person Centred Planning course recently, and are in the early stages of introducing new documentation that will ensure service user wishes, goals and ideas are clearly considered and recorded within their personal plans. This documentation is in a format that will be easy to understand for all service users. The manager is addressing health and Safety issues, and records indicated that appropriate checks such as fire alarm testing and water temperatures checks were being done weekly. Fire Evacuation Drill was being done monthly. However the Maglocks on some of the fire doors were not working. The manager stated that the replacements for these were still waiting final approval. Being kept waiting for these was unacceptable and could leave the service users at risk. Vaughan House DS0000014979.V334000.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 3 2 3 3 3 4 X 5 3 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 2 25 3 26 3 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 2 X 3 3 2 X 2 2 X Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement All service users must be assessed for their ability to selfmedicate. This assessment should be reviewed regularly and the appropriate support offered. Timescale for action 01/09/07 2. YA24 16(2)(c)) All the redecoration in the home, including service users bedrooms, must be completed by September. This date has been extended because of the delay in the new floor being laid in the lounge area. 31/05/07 3. YA39 24 (1)(a)(b) The home must have an effective 01/09/07 quality assurance system that influences the annual development plan for the home. This standard was partially met Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Vaughan House DS0000014979.V334000.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!