Inspection on 04/05/06 for Whistley Dene

This inspection was carried out on 4th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whistley Dene 30/09/08

Whistley Dene 12/01/06

Whistley Dene 08/07/05

Whistley Dene 09/12/04

Whistley Dene 25/06/04

Whistley Dene 06/11/03

Whistley Dene 01/05/03

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

CARE HOME ADULTS 18-65 Whistley Dene Whistley Road Potterne Devizes Wiltshire SN10 5TD Lead Inspector Pauline Lintern Key Unannounced Inspection 4th May 2006 10:00 Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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 Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Whistley Dene Address Whistley Road Potterne Devizes Wiltshire SN10 5TD 01380 721913 01380 721913 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) White Horse Care Trust Mrs Tina Tracy Shaw Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: Whistley Dene provides care and accommodation to men and women who have a learning disability and who may also have a sensory loss or associated physical disability. The house is located in a hamlet on the edge of the village of Potterne, which is located 3 miles from Devizes town centre. The home provides high standards of spacious accommodation with extensive and well-maintained grounds. Each service user has their own bedroom. Typically three support workers throughout the waking day staff the home. At nighttime one member of staff sleeps in and is expected to respond to any emergencies or night time care needs as they arise. The home has its own vehicle, which is used to access a range of day services and to ensure community presence. Whistley Dene is one of a number of homes operated by the White Horse Care Trust. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection was completed over five and a half hours. The inspector met with five service users, however was only able to communicate with one person to obtain their views. The manager was available throughout the inspection. Due to training taking place there was five staff at the home and the inspector had the opportunity to meet with them all. The physiotherapist visited service users in the afternoon and was able to share their observations with the inspector. One service user survey was left at the home for one service user that was at the day centre to complete. This was returned to the commission and contained positive comments. Letters have been sent out to four relatives, one social worker and three GP’s for their views on the service. Two responses have been received. The basic rate for this service is £1,376.29p per week. Care plans for three service user’s were sampled together with risk assessments, medication records and health and safety records. The judgements contained in this report have been made from evidence gathered during the inspection, which takes into account the views and experiences of people using the service. What the service does well: On the day of the inspection it was evident that the manager and staff team provide a clean, pleasant and homely environment for the service users living there. The staff report that they feel that they are supported well by their manager. Training offered covers various specialist topics as well as the required mandatory subjects. Staff are able to request specific training if they feel that it is required. Care plans are informative and aim to ensure the needs of the service users are met. The location of the home is very rural, however the staff ensure that this does not impinge on opportunities to access activities in the local and wider community. It is reported that the home is very good at communicating with external agencies. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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 Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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 the following standard(s): 2 Evidence shows that service users aspirations and needs are assessed. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visits to this service. EVIDENCE: Care plans sampled show that a full assessment has been made to ensure that the home can meet the needs of prospective service users. The assessment covers all areas of the service users needs, including accommodation, personal support, cultural, health, risk, and communication needs. Service user’s assessments showed that they had the opportunity to visit the home prior to moving in and two service users had slept over. Staff members reported that it was particularly nice for one service user as they recognised people already living at the home from the local day centre. Records show that one service user was asked if they were happy and they replied ‘I want to stay here, they cook good food here’. One service user survey returned stated that they were asked if they wanted to move into the home. They confirmed that they had been provided with enough information about the home to enable them to decide if it was the right place for them. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Service users have their needs and goals reflected in their care plan. With assistance service users are able to make decisions about the way they live their lives. Risk assessments are in place to enable service users to lead an independent lifestyle where possible. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Reports submitted to the commission from the responsible individual’s monthly visits confirm that risk assessments are being reviewed regularly. Each care plan examined indicated that all risk assessments are being reviewed, according to the service users changing needs. One care plan showed that staff have identified that the service user had no awareness of road safety and a risk assessment had been drawn up to ensure that all potential risks are minimised. Each care plan has a review calendar, which allows the reader to identify important review dates. One service user’s care plan show that they attended their last meeting and identified some activities, which they would like to participate in, such as going to France on a boat. Records demonstrate how Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 Page 10 staff intend to enable the service user to achieve their goals by means of an action plan. All action plans have evidence of progress. Family members are encouraged to participate in the development of service user’s care plans when appropriate. The responsible individual for the service confirms that one of the newer service users care plans is ‘comprehensive, useful and updated regularly as their needs become more known’ and that their risk assessment ‘remains under review’. One survey returned from a service user stated that they ‘sometimes’ make decisions about what they do each day. Staff are able to recognise facial expressions of one service user, which shows if they are happy or not. Although one service user is unable to make an informed choice, they are able to choose what to wear and pick colours for their bedroom. Staff have identified that making choices can be stressful for one service user, and they often decline new choices. The manager reported that when this happens staff will reassure the service user by confirming that if they wish to try a new experience and then wishes to come home they can do so straight away. Care plans demonstrate that staff have considered the diverse needs of the service users and ensure that they promote equality. The home provides a sensory room for service users with a visual impairment. Staff confirm that service users enjoy the facility of the bubble tube, hot water bed and fibre optic lights. Service users have the opportunity to attend church if they wish and this is documented in their care plans. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Most service users have the opportunity to participate in activities both inside and outside of the home. One service user is finding it difficult to access the home’s vehicle. Service users are encouraged to maintain relationships with friends and families. Service users are treated with respect. Meal times are relaxed and the food is nutritionally balanced. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Care plans and the house diary show that service users attend various appropriate activities. Service user’s attend Wyvern College, Ashton street, Devizes Community resource centre and Marlborough resource centre where activities include cooking, communication, woodwork, art, craft, singing, dancing and music relaxation. At the local gateway club service users can enjoy skittles and bingo sessions. The Trust holds their own ‘crafty club’, in different homes monthly. This enables service users to meet friends from other services. Given that the location of Whistley Dene is very rural staff ensure that service users access the local community with trips to the library Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 Page 12 and the local church and social club, where staff report all service users are well known and made to feel welcome. One service user’s life book has photographs in of past visits to the seaside, animal parks, zoos and holidays. Each service user has an activity plan for the week in their care plan. There is a local hydrotherapy pool which many service users take advantage of with staff support. Comments made by one service user on the survey, stated that they enjoyed buying a lottery ticket. Staff confirmed that they support them with this activity and the home has clear guidelines in place to safeguard the individual and the staff members. Comments returned from survey’s sent out by the commission raised concerns that one service user is experiencing difficulties accessing the vehicle due to their mobility, however they are contributing to the cost of the vehicle. The inspector felt that this indicated that the home is not meeting the needs of this person. Discussion with the manager confirmed that they have identified that the present vehicle is not appropriate for the needs of this individual at the present time. The manager confirmed that to alleviate this problem in the interim they have arranged to borrow a more suitable vehicle from another home one day a week. This is an outcome group that the home do excel in and they are clearly trying to rectify this situation. The manager reports that the home encourages family and friends to visit at any time. One relative commented to the inspector that they would like it if the home could make provision for the service user to visit a relative at their home. The manager confirmed that this had already taken place with staff supporting the service user on the trip. Staff were observed respecting service users, by enabling them to spend time alone if they wished. The layout of the home allows service users to distance themselves from others if they so wish. One service user was supported to their bedroom to rest after lunch. Staff spoke to them in a calm and friendly manner, played some soothing music for them and checked on them later to see if they were ready to return to the lounge. One service user has a kitten, which they are very fond of. Staff support them to look after it and a risk assessment is in place to ensure that the health and safety of service users is not jeopardised. During lunchtime the staff were observed interacting with service users. It was clear that mealtimes are a social event with lots of chatting and laughing with the service users. During the meal the inspector had the opportunity to talk to one service user, with support from their key worker and other staff members. Recent purchases were discussed and staff explained how they promote choice, when purchasing clothes. The meal on the day of the inspection included bagels and a mixed salad. The menus sampled showed that varied and nutritional meals are served. Staff reported that they tend to keep to fairly plain food, as this is what the service users prefer. Staff report that the ‘food is good’. On occasion a take away is bought however due to the location of the home this is not always easy. Staff confirmed that service users choose to eat together but are able to eat alone if they wished. Records of behavioural techniques in daily records needs to more fully describe the action taken. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Staff ensure that service users receive personal care in a way they prefer and require. Provision is made to ensure service user’s health needs are met. No service users are able to self-administer their medication. The home has medication policies and procedures to protect service users. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users with a visual impairment were observed being supported by the staff when moving around the home. Staff report that some service users are able to map their way around the home independently. Staff were seen reassuring service users who have limited mobility. Where guidance and support is required with personal care, it is documented in the care plans. Service users choose how to wear their hair and staff offer support with grooming if it is required. One service user had recently chosen to have their hair coloured and was keen to show it off. Staff empower one service user to express their sexuality by supporting them to buy nice clothes and helping to paint their nails and apply their makeup. During the inspection the physiotherapist visited a service user to provide an aromatherapy session. When asked for comments on the service provided at Whistley Dene, they included: ‘I have no concerns about the care provided in Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 Page 14 this service’, ‘staff are always happy to receive advice’ and’ service users are well cared for’. Staff were observed ensuring that one service user took their daily exercise and ensured that they had used their inhaler prior to the activity. One staff member had not used the inhaler before and was shown by another member of staff. There was also clear guidance in the care plan on the correct way to use the ‘spacer’. Records demonstrate that health care appointments are made with opticians, dentists, GP’s and any other specialist support, which may be required. There is a epilepsy management plan for one service user and all seizures are recorded. All staff, except one new person have received training in administering rectal diazepam. The manager reported that it was rarely needed, but staff are trained as a precautionary measure. It has been identified that one new service user needed to have their eyes tested. Staff reported that now they have new glasses it has ‘transformed their life’. Evidence shows that service user’s medical needs are reviewed on a regular basis. Reports sent to the commission state that one service users changing needs are ‘well managed and reviewed in a multi-disciplinary way’. Three service users medication records were sampled and all medication was recorded appropriately. A stock sheet shows in/out and returns of any medication. The home has a ‘drop’ bottle to keep any unused tablets in. All staff have to be deemed competent by the manager before they administer any medication. This is after a three-month period to ensure the safety of service users. One care plan stated that their medication is mixed with jam. The information was rather confusing for the reader. It was recommended to the manager that this information is made clearer and that consent for this procedure is sought from the family or advocate of the service user, their GP and their care manager.. Most of the service users at the home are unable to give their consent to medication, however where this is possible it is required that this is obtained. For the service users who are unable to consent, then again it should be obtained from their family if possible. To ensure that no errors occur whilst administering medication, it is recommended that each medication file has a photograph of the service user on the front to identify them. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23 The home has clear and effective complaints procedures to ensure service users feel their views are listened to. Where possible service users are protected from potential abuse of any kind. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: In line with the Trust’s procedures each service user has a ‘complaints postcard’ in their file that is already addressed for them to send if they wish to raise a concern. One service user reported that they do know how to make a complaint if they needed to. The manager confirmed that all next of kin have a copy of the complaints procedure. It is required that the manager ensures that each service user guide has a copy of the complaints procedure in a format that makes sense to him or her. The manager reports that there have been no complaints since the last inspection, but many compliments. The complaints log supported this statement. The log contains space for actions and outcomes and timescales. One service user commented that they knew who to speak to if they were not happy and that they knew how to make a complaint. Discussion with the staff indicated an awareness of the ‘whistle blowing’ policy and the procedure for reporting a suspicion of abuse. One staff member said that they would ‘go to the manager if they suspected abuse was taking place or go higher if necessary’. All staff that spoke to the inspector confirmed that they have received training in adult protection and had seen the ‘No Secrets’ guidance. The home has a flow chart on the wall for potential alerters. The home sent out a survey in 2005. Three questionnaires were sent out to families and two replied. 97 agreed with the comment ‘any concerns that I have are always listened to’. 97 confirmed that they had a copy of the complaints procedure. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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 the following standard(s): 24 and 30 Whistley Dene is a homely, comfortable and safe environment for service users to live in. The home is clean and hygienic. Quality for this outcome is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The premises are in keeping with the local community and have a style and ambience that reflects the home’s purpose. The home is spacious and is accessible for service users with mobility difficulties. The premises meet the requirements of the local fire service and environmental health department. The grounds are in exceptional order and are maintained by a gardener. The Trust employs an odd job man to carry out small maintenance jobs. West Wiltshire housing completes any structural repairs. All furnishings and fittings are of a high standard and fulfil their purpose. At the time of the inspection the house had no unpleasant odours and it was apparent that the staff take a pride in their environment. During the tour of the building there was evidence that measures are in place to reduce the risk of infection. Staff confirmed that they are provided with protective clothing. Bathrooms contained boxes of gloves for staff use. The Trust has a representative for infection control in the home. This staff member Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 Page 17 confirmed they had attended training and then she carries out refresher training with staff during team meetings. Laundry facilities meet the required standard. The floors are clean and no soiled laundry is taken near food preparation areas. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 The staff team appear competent and qualified to carry out their duties. Recruitment records could not show that service users are protected. The home has a comprehensive training and development programme in place. Staff are supervised appropriately. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The managers confirmed that most of the recruitment records are held at their Head office and therefore were not available for examination. It is a requirement that all recruitment records are available for the inspector to sample. The recruitment records of one new staff member were at the home and showed that two references and a CRB check had been completed. This staff member confirmed that they are receiving an induction, which takes three months to complete. Their induction programme showed that all areas of the service are covered during this period. Each staff member has a training assessment and the home has a comprehensive training and development programme for 2006. Staff members commented that ‘training is excellent’ with refresher courses available. They added that if specialist training is needed ‘Tina will arrange it’. On the day of the inspection refresher training for Manual handling was taking place. The manager explained that they had Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 Page 19 identified a need for this training, as they were experiencing difficulties enabling one service user to access the vehicle. Some of the topics covered in training are O’Brien’s principles, person centred planning, downs syndrome, signalong, abuse awareness, aging process, supervision and epilepsy. Staff report that they identified a need for training in sensory loss and this had been arranged by the manager and accessed through external trainers. This enabled the staff to ensure that the diverse needs of the service users were being met. The house diary identifies the days when training is due to take place. And staff have their own training matrix where they record when training has been completed. Staff use the Learning Disability Framework Award to provide underpinning knowledge prior to commencing with their NVQ’s. The home has experience some difficulties in the past with recruitment due to the location of the home. The manager reported that this has now improved and they only have one staff vacancy at the time of the inspection. Staff who spoke to the inspector confirmed that staffing levels had improved and this had impacted on the service users. The staff rota showed that 3 staff are on duty during the day with 1 sleeping in at night. Staff confirmed that they receive regular supervision from their line manager. Supervision records show that staff’s training needs are discussed within their supervision. Staff comments included; ‘Tina is very good’, ‘Tina is very supportive’, ‘the Trust are very good but we still have a moan sometimes’. One service user remarked that ’staff always treat me well’. Team meetings take place in the home regularly. Minutes from the last meeting on 19/04/06 demonstrated that there is a good attendance. Staff told the inspector that sometimes service users would also join in the meeting with the staff. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 The home is well run, which benefits the service users, however some health and safety aspects need to be addressed to ensure the safety of the service users. Service users views underpin the review and development of the service. Records need to show that they have been reviewed regularly. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The registered manager has just completed her Registered Manager’s Award and is now waiting for it to be verified. It is clear from discussion with the staff team that Mrs Shaw is thought very highly of as a manager. She confirmed that she attends Trust manager’s meetings once a month, where she is able to meet up with other managers. The home has a new Quality assurance tool in place for 2006, which includes questionnaires being sent out to families, service users, advocates and healthcare professionals. The last survey sent to families showed that 91 reported that they are ‘happy with the care provided’. The Trust also sends out Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 Page 21 a newsletter to families. Surveys returned to the commission confirmed that Whistley Dene provide a good standard of care to the people living there. During the tour of the home the cupboards that store the hazardous materials were found unlocked. All of the keys to the cupboards in the utility room had been left in the locks. This was reported back to the manager and a requirement has been made that ensures all COSHH materials are locked securely away at all times. The data files for these materials were accurate. One member of staff is the home’s representative for collating data and ensuring staff receive refresher training. There was documentation to show that regular health and safety checks have taken place. All fire logs were up to date and a generic fire risk assessment in place. The staff member responsible for fire records and training reported to the inspector that staff are regularly given questions on fire prevention during the staff meeting to ensure they have a sound knowledge. There is a risk assessment in place for Legionella and for ‘safe systems at work’. All staff attend manual handling training and complete refresher training. During the inspection a manual handling assessment was being carried out with the trainer to assess the needs of one service user accessing the home’s vehicle. A few of the guidelines in the service user’s files do not evidence that they have been reviewed recently. The manager agreed that the contents has probably not changed, however she will ensure that they are all re-visited to ensure that the information given is still current. It is recommended that service user’s files have a photograph of them on the front. This may help them to have ownership of their personal file and to realise that the file is about them. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 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 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X 3 2 x Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 Page 23 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 Requirement Timescale for action 04/06/06 2 YA22 3 YA34 4 YA42 13(2)Schedule The registered manager must 3. 3(M) ensure that all protocols for administering medication are clear and that consent is obtained and recorded. 22(6) The registered manager must 04/07/06 ensure that each service user has a copy of the complaints procedure in an appropriate format. 17(2) The registered person must 04/06/06 Schedule4 ensure that all recruitment (6a,b,c,d,e,f) records are kept in the home available for inspection. 13(3) The registered manager must 04/05/06 ensure that all toxic chemicals are securely locked away. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA41 YA41 YA13 Good Practice Recommendations It is recommended that the registered manager place a photograph on the front of each service users file so that they know the file belongs to them. It is recommended that all guidelines be reviewed regularly and dated. It is recommended that the suitability of the present home’s vehicle is assessed to ensure it is meeting the needs of all of the service users. Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Whistley Dene DS0000028585.V292661.R01.S.doc Version 5.1 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. 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