Inspection on 24/05/07 for White Barn

This inspection was carried out on 24th May 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

White Barn 20/05/08

White Barn 08/12/05

White Barn 20/07/05

White Barn 15/12/04

White Barn 09/08/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 White Barn 45 Cressingham Road Reading Berkshire RG2 7RU Lead Inspector Marie Carvell Unannounced Inspection 24th May 2007 12.20 White Barn DS0000011070.V342687.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 White Barn DS0000011070.V342687.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. White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service White Barn Address 45 Cressingham Road Reading Berkshire RG2 7RU 0118 987 3190 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) paula.cox@kingwood.org.uk The Kingwood Trust Miss Paula Marie Cox Care Home 5 Category(ies) of Learning disability (5) registration, with number of places White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: White Barn provides twenty-four hour residential care to five service users, of both sexes, who have learning and associated behavioural difficulties. The home is a large two-storied building with all the individual accommodation on the first floor. The building is owned and the care is provided by the Kingswood Trust, a charitable organisation. White Barn is situated a few miles from Reading Town Centre and there are local facilities within walking distance. The home has its own vehicle and it is on a main public transport route. The current scales of charges as at May 2007 are between £ 1426.00 and £1757.00 per week. There are no additional charges. White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘key Inspection’. The inspector arrived at the service at 12.20pm and was in the service until 6.00pm. It was a thorough look at how well the service was doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection. Relatives of four service users responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standards of the service. Time was spent with several of the service users, the manager and staff on duty, a tour of the premises was carried out and a sample of records required to be kept in the home were examined, including the case tracking of two service user’s files. Some brief feedback was given to the manager, during the inspection. Both the manager and deputy manager had to leave before the inspection was completed, due to other commitments. What the service does well: Care plans are completed with input from the service user, key worker and the service user’s representatives, as appropriate. Care plans are detailed and include behavioural support needs and guidelines, the likes, dislikes and preferences of the service user, daily routines and activity programmes. Care plans are updated each month by the service user’s key worker. Regular review meetings are held to ensure that any changing needs are being addressed. Risk assessments are in place to support care plans and are used to inform staff of the ability of service users to make informed choices and decisions. From discussion with staff on duty and observation, all staff were able to demonstrate a clear knowledge of the service users needs and preferred lifestyle. From observation service users were treated with dignity and respect from members of staff. It was evident that there is a good rapport between service users, staff on duty and the manager. All service users have a weekly programme of activities. Activities undertaken are recorded on a daily basis in service user records. The home has its own vehicle, which is well used for outings. None of the service users completed a White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 6 survey, but during the inspection, several service users spent time with the inspector and describing activities and hobbies. One service user said that he ‘liked to play football in the garden with X’, another service user has recently been on a holiday to New York accompanied by home staff. Several service users enjoy using the computer in the activity room. Comments received from relatives who returned surveys included ‘ The home can take our son/daughter on a short holiday, but it tends to be a strain on staffing levels’, ‘X has a timetable which includes activities he/she enjoys. He/she does a variety of things. But how can we know definitely what he/she would choose if able?’, ‘X has a really good life and has a fantastic programme, which covers all the day to day activities, social events and of course holidays’, ‘X leads a varied lifestyle. X eats well and is physically cared for. Staff give him/her friendship and emotional support’. Visitors to the home are made welcome. Birthdays and other events in the home always include families and friends. Service users are supported to write letters to family members and friends and maintain regular contact. Daily routines are relaxed and flexible to meet the service users’ preferences, this is made possible as three service users have been assessed as requiring 11 support between 8am and 10pm and two service users have been assessed as requiring 1-2 support between 8am and 10pm. From discussion with the manager, comments recorded on a survey received from a parent and direct observation, the home is able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. What has improved since the last inspection? What they could do better: Medication administration records, showed an ongoing discrepancy between the times of medication to be administered to one service user, as prescribed by the GP, and the time given. This was discussed with the manager, who agreed to address the discrepancy. The information contained in the complaints procedure is out of date and needs updating. Staff need to be aware of the home’s whistle blowing policy. Bathrooms and toilets were seen to be clean, but were very shabby and in urgent need of the planned refurbishment. White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 7 Staffing levels are adequate to meet the needs of the service users, but are dependent on agency staff to cover staff vacancies. From examination of three staff personnel records, not all pre-employment checks were on file. The inspector was advised that the 2007/8 staff training and development programme was not yet available. The manager confirmed that most staff are not receiving regular, planned supervision a minimum of six times per year. Several members of staff have not received formal supervision for more than twelve months; the manager said that the reason that regular supervision was not taking place was due to staff shortages and other commitments. It is not evident that the manager has sufficient time to carry out some of her administrative and management responsibilities at White Barn, whilst needing to spend time at a third service, carrying out such tasks as shopping. Policies and procedures are in place and need to be revised and updated. The manager said that all policies were being updated by the Policies Committee, and should be completed by June 2007. There is an annual Team Plan for the service, undertaken by the Service Manager and includes development of the home, budgets and staffing. This has not been updated since September 2005. Proprietor representative visits to the home are not undertaken on a monthly basis. The last report available was dated 30th January 2007; the manager said that this was due to several changes to senior management. Quality Assurance processes need to be developed to include seeking the views of other stakeholders. As part of the home’ quality assurance process, questionnaires were sent to parents in November 2006. The information received has not yet been collated. White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 8 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. White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 9 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 White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 10 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): Standard 2 and 4. Quality in this outcome area is good. All service users are assessed prior to moving into the home and are given the opportunity to visit the home before moving in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The five service users have lived together in the home for a number of years. Previous inspection information has indicated that all service users have, had a full assessment undertaken prior to moving into the home. There is an admission procedure in place. White Barn DS0000011070.V342687.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): Standards 6,7 and 9. Quality in this outcome area is excellent. Service users have detailed care plans and are involved as much as possible, with decision making. Appropriate risk assessments are in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are completed with input from the service user, key worker and the service user’s representatives, as appropriate. Care plans are detailed and include behavioural support needs and guidelines, the likes, dislikes and preferences of the service user, daily routines and activity programmes. Care plans are updated each month by the service user’s key worker. Regular review meetings are held to ensure that any changing needs are being addressed. Risk assessments are in place to support care plans and are used to inform staff of the ability of service users to make informed choices and decisions. White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 12 From discussion with staff on duty and observation, all staff were able to demonstrate a clear knowledge of the service users needs and preferred lifestyle. From observation service users were treated with dignity and respect from members of staff. It was evident that there is a good rapport between service users, staff on duty and the manager. Staff on duty were observed promoting choice and decisions made by the service users using a variety of communication methods. Service users, who were able to communicate verbally, were able to name their key worker. Surveys completed by relatives of service users confirmed that they are kept informed of important matters affecting their relative. Comments made included ‘we are kept informed of most happenings. Some staff are more informative than others, but we can always speak to those most involved with X’ and ‘they are very good at encouraging contact between family and friends’. Service user records seen were well maintained, detailed and up to date. White Barn DS0000011070.V342687.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): Standards 12,13, 15, 16 and 17. Quality in this outcome area is good. Service users are assisted to make informed choices regarding all aspects of their daily life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users have a weekly programme of activities. Activities undertaken are recorded on a daily basis in service user records. The home has its own vehicle, which is well used for outings. None of the service users completed a survey, but during the inspection, several service users spent time with the inspector and describing activities and hobbies. One service user said that he ‘liked to play football in the garden with X’, another service user has recently been on a holiday to New York accompanied by home staff. Several service users enjoy using the computer in the activity room. Comments received from relatives who returned surveys included ‘ The home can take our son/daughter White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 14 on a short holiday, but it tends to be a strain on staffing levels’, ‘X has a timetable which includes activities he/she enjoys. He/she does a variety of things. But how can we know definitely what he/she would choose if able?’, ‘X has a really good life and has a fantastic programme, which covers all the day to day activities, social events and of course holidays’, ‘X leads a varied lifestyle. X eats well and is physically cared for. Staff give him/her friendship and emotional support’. Service user’s rights and responsibilities are respected and this is evidenced in service user records. The right to be alone is respected by staff, service users are able to lock their bedroom doors with a key and staff do not enter bedrooms without permission. Visitors to the home are made welcome. Birthdays and other events in the home always include families and friends. Service users are supported to write letters to family members and friends and maintain regular contact. Daily routines are relaxed and flexible to meet the service users’ preferences, this is made possible as three service users have been assessed as requiring 11 support between 8am and 10pm and two service users have been assessed as requiring 1-2 support between 8am and 10pm. From discussion with the manager, comments recorded on a survey received from a parent and direct observation, the home is able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Menus are planned around the food preferences of the service users. Service users choose whatever they would like for breakfast and lunch. The evening meal is planned, taking into consideration service users likes and dislikes. The inspector observed the evening meal being served, with all staff sitting down with service users and chatting about the days events and activities planned for the evening. Food stocks were plentiful, with fresh fruit, salad and vegetables. Records of meals provided were well maintained. One service user said that he/she enjoyed the meals and the food ‘was good’. White Barn DS0000011070.V342687.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): Standards 18,19 and 20. Quality in this outcome area is good. Service user’s personal and healthcare needs are well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users physical and personal support needs are detailed in care plans and recorded daily in service user records. Service user’s records evidenced that regular healthcare checks take place and that healthcare professionals are available when needed. Comments received from relatives included ‘ I am impressed by all aspects of care that X is receiving at White Barn’ and ‘we discuss medical matters including dentistry’ Medication is administered by staff who have received appropriate medication training. There is a staff signature list and medication guidelines are in place. Medication administration records, showed an ongoing discrepancy between the times of medication to be administered to one service user, as prescribed White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 16 by the GP, and the time given. This was discussed with the manager, who agreed to address the discrepancy. White Barn DS0000011070.V342687.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): Standards 22 and 23. Quality in this outcome area is adequate. The homes has a complaints procedure in an appropriate format for service users, the procedure needs to be updated. Procedures are in place to protect service users from abuse. Staff need to be aware of the home’s whistle blowing policy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure in place and is available in pictorial format for service users. The information contained in the complaints procedure is out of date and needs updating to include the name and address of the provider representative, who is able to deal with complaints, the Commission and the complaints procedures for the funding authorities. Comments made on surveys completed by relatives included ‘ I would need to look up what to do. This would not be a problem’, ‘ never had too’, ‘ we normally would go via the key worker, then to the manager and then to Kingswood Trust’, ‘ we have no complaints about our sons/daughters care’. Staff were very clear that if a service user was unhappy, then this would be expressed through changes in their behaviour. There was no complaints recorded in the complaints book and the Commission has received no information regarding complaints about this service since the last inspection. All staff have received training in safeguarding vulnerable adults from abuse. This was confirmed by staff on duty and evidenced in training records. Staff White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 18 spoken to were unclear about the home’s whistle blowing policy or if there was a policy in place. All service users depend on the manager and staff team to manage their personal allowance on their behalf. Clear, well maintained records are kept of all service users’ finances. White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,25,26,27,28 and 30. Quality in this outcome area is good. Service users live in a homely and comfortable environment. Refurbishment of some parts of the home is due to take place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection some areas of the home have been redecorated and new furniture purchased. The bathrooms and toilets are due to be refurbished and the manager is waiting to be given a date for the work to commence. One bedroom was seen at the invitation of the service user. The room was comfortably, appropriately furnished and reflected the interests of the service user and personalised with photographs of family, friends and holidays taken. The service user was involved in the cleaning of his/her bedroom and clearly took pride, in maintaining a high standard. White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 20 Bathrooms and toilets were seen to be clean, but were very shabby and in urgent need of the planned refurbishment. The communal areas of the home consist of a large sitting room, a smaller sitting room, a sensory room and a large dining room. The staff team have worked hard to make the home comfortable, homely and welcoming. The home has a well equipped laundry. The washing machine has a sluicing facility. Policies and procedures are in place regarding infection control measures and all staff have received health and safety training. All parts of the home were seen to be clean, fresh smelling and hygienic. White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34, 35 and 36. Quality in this outcome area is good. Staffing levels are adequate to meet the needs of the service users, but are dependent on agency staff to cover staff vacancies. Recruitment procedures protect service users from harm. Not all staff receive formal supervision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff on duty were clear about their roles and responsibilities. Since the last inspection four members of staff have left and three members of staff have been recruited. The home currently has vacancies for three full time support workers. The inspector was advised that staff are not being recruited for these positions at present and the hours are being covered by existing staff working additional hours and agency staff. During an eight week period, 400.5 individual shifts were covered by staff working additional hours or agency staff. There is always a minimum of four staff on duty during daytime shifts. Staff on duty said that the staff team worked well together. In discussion with staff and observation it was evident that they are aware of the service users White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 22 wishes and choices. Staff were observed carrying out their duties patience and good humour. When asked staff were knowledgeable about individual care needs and behavioural guidelines in place. From examination of three staff personnel records, not all pre-employment checks were on file. None of the three files had a recent photograph of the staff member, one file contained only one reference and no evidence of police checks being completed and another file contained no evidence of police checks being completed. All files contained evidence of an interview being conducted by two senior members of staff. The manager contacted the organisations human resources department during the inspection, and it was agreed that references and evidence of police checks would be sent to the home to be placed on file. The Commission received confirmation the following day that references and police checks had been completed prior to employment in the home. The manager has agreed to update all staff photographs. There is a staff team of a deputy manager, who provides direct care to service users for sixteen hours per week, two support workers enhanced (seniors), seven full time support workers and a part time support worker working twenty two hours per week. The deputy manager has completed NVQ level IV in care and management, four support workers have achieved NVQ level III, one support worker has achieved NVQ level II and three support workers are working towards NVQ level III. Evidence was available of training undertaken by staff during the last year. The inspector was advised that the 2007/8 staff training and development programme was not yet available. The manager confirmed that most staff are not receiving regular, planned supervision a minimum of six times per year. Several members of staff have not received formal supervision for more than twelve months; the manager said that the reason that regular supervision was not taking place was due to staff shortages and other commitments. All staff with supervisory responsibility have completed supervisory training. In discussion with staff on duty, most felt well supported. Comments made on surveys completed by relatives included ‘the staff, several of whom have worked there since X started living there have an excellent understanding of him/her and autism. They work extremely hard to make him/her settled, secure and happy’, ‘there are always experienced staff on duty, although obviously new staff members do not have the same experience, most seem to grow into it. All staff have a basis understanding of autism which helps them to care and act appropriately’, ‘staff appear to be professional and I have not seen anything to change my mind. My son/daughter is a very happy young man/lady and enjoys Whitebarn and the staff company. They treat him/her very well’, ‘ staffing seems to be cyclical as staff can leave. Currently we are the top of the cycle and all staff are good’. Staff meetings are held on a regular basis and minute of meetings held in October 2006, June 2006 and March 2006 were available for examination. White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 23 Handovers take place and the start of a shift and staff said that communication between support staff and senior staff is good. White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 24 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): Standards 37,39,40,42 and 43. Quality in this outcome area is adequate. The manager must be provided with sufficient time and resources to manage the home effectively. Effective quality assurance procedures must be put into place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An experienced and well qualified registered manager has been in post since April 2005. She has completed NVQ level IV in care and management and the registered manager award. The manager is also the registered manager for a second home in Oxfordshire and divides her time between the two homes. In addition since April, she has been assisting with a third service. Staff at White Barn were advised that the manager would be ‘contactable as and when White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 25 required’. Duty rosters showed that some weeks the manager was only at White Barn for short periods. It is not evident that the manager has sufficient time to carry out some of her administrative and management responsibilities at White Barn, whilst needing to spend time at a third service, carrying out such tasks as shopping. Service user records were well maintained, although other records needed updating. Policies and procedures are in place and need to be revised and updated. The manager said that all policies were being updated by the Policies Committee, and should be completed by June 2007. There is an annual Team Plan for the service, undertaken by the Service Manager and includes development of the home, budgets and staffing. This has not been updated since September 2005. Proprietor representative visits to the home are not undertaken on a monthly basis. The last report available was dated 30th January 2007; the manager said that this was due to several changes to senior management. Quality Assurance processes need to be developed to include seeking the views of other stakeholders. As part of the home’ quality assurance process, questionnaires were sent to parents in November 2006. The information received has not yet been collated. A sample of records relating to health and safety were examined and seen to be well maintained and up to date. White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 26 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 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 2 2 x 3 2 White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 27 N/A 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 YA22 Regulation 22 Requirement Information in the complaints procedure should be up to date, so complainants know the correct process and who to speak to. All staff must receive regular, recorded supervision at least six times per year. Sufficient time must be given to the manager to effectively manage the home. An annual business and development plan is put into place for 2007/08. Reports on the conduct of the home written by a provider representative, following an unannounced visit to the home on a monthly basis, must be available for inspection. Timescale for action 22/07/07 2 3 4 5 YA36 YA37 YA43 18 24 24 26 22/07/07 22/07/07 22/08/07 22/07/07 YA43 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. White Barn Refer to Good Practice Recommendations DS0000011070.V342687.R01.S.doc Version 5.2 Page 28 1 2 3 4 Standard YA23 YA33 YA35 YA43 That consideration is given to updating all staff in the home’s whistle blowing policy. Permanent staff are recruited the current vacancies, to ensure consistency of staff cover in the home. That a staff training and development programme is put into place for 2007/08. That consideration is given to including the views of other stakeholders in the home’s quality assurance process. White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 White Barn DS0000011070.V342687.R01.S.doc Version 5.2 Page 30 - 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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