Inspection on 11/07/06 for Willes Road

This inspection was carried out on 11th July 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Willes Road 18/07/08

Willes Road 19/11/07

Willes Road 04/07/07

Willes Road 29/11/05

Willes Road 19/05/05

Willes Road 26/10/04

Willes Road 14/05/04

Willes Road 03/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 26 Willes Road 26 Willes Road Leamington Spa Warwickshire CV31 1BN Lead Inspector Martin Brown Key Unannounced Inspection 11th July 2006 09:30 26 Willes Road DS0000058002.V303761.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 26 Willes Road DS0000058002.V303761.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. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 26 Willes Road Address 26 Willes Road Leamington Spa Warwickshire CV31 1BN 01926 336437 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) Turning Point Mrs Samantha Ann Wilkes Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered manager must successfully complete the Registered managers Award and NVQ level 4 by 1st November 2006. 29th November 2005 Date of last inspection Brief Description of the Service: This house is home to five young people who have significant learning difficulties, impaired communication skills and complex behaviours. All are able bodied. The service offers 24-hour staffing and high levels of intensive support and personal care. 26 Willes Road is a Georgian detached house that has been divided into two separate, self-contained dwellings. The top two floors provide three bedrooms (one with en-suite), two lounges, one dining room, kitchen, laundry, one bathroom and separate toilet and staff office for three people with severe learning difficulties. The basement provides accommodation for two young men. There is a rear entrance, two bedrooms, one bathroom, a small lounge and a small kitchen. There is a storage space that has been converted into an office come laundry. The fees currently range from £1,430 to £2,501. There are additional charges for transport; a £400 allowance is made towards an annual holiday. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been made using evidence that has been accumulated by the Commission for Social Care Inspection. This includes information provided by the home, and a visit to the home. Feedback cards for service users and relatives were sent to the home but none were received back. The inspection visit was unannounced and took place on 11th July 2006, between 9.30 am and 4.30pm. All service users were seen over the course of the inspection, as were staff on both the morning and afternoon shifts. A tour of the premises was made, relevant documentation was looked at, and observations of the interactions between service users, staff and their environment were made. Despite communication difficulties, service users were able, where they wished, to express some views, mostly in single words, and to people they felt confident and secure with. Staff were helpful throughout, as was the agency manager, who had been in the post less than a month. What the service does well: What has improved since the last inspection? What they could do better: In spite of the overall excellence of practice observed, there was some poor practice, such as a medication record sheet being left out, and a service user being held by the wrist in an overly physical manner was observed, which needs to be guarded against. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 6 The complex needs of the service users make it vital that agreed guidelines are adhered to at all times, and that safety is kept paramount. Environmental improvements must continue, with carpeting being replaced as necessary, and repairs carried out promptly. The absence of a permanent, registered manager, and the issues surrounding that absence, must be resolved as speedily as possible. 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. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion, as it has previously been agreed that there are to be no new admissions to the home. EVIDENCE: 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Individual care plans and guidance support individuals in having their needs met, and they are supported to take risks and make decisions. EVIDENCE: A sample of service users files were looked at. These are kept in service users’ bedrooms, and include a comprehensive file including guidance on individual needs and how they are to be met, and what individual risks are and how they are managed. There are detailed files containing reviews and health information, and user-friendly files, containing guidance on wishes, preferences and support needs, well-illustrated with photographs. The user-friendly guides looked at did not detail a specific date for review. Staff were observed to be asking and ascertaining service users agreement with plans for the day. One service user was asked who he would like to go to a disco later in the week with, and was able to respond with a name which the staff member duly noted, with the intention of meeting that expressed preference. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 10 Risk assessments, often in the form of first person guidance, show how individual risks manifest and how they are best managed. Active support plans give a template for each service user’s day, providing a range of activities that meet their needs and preferences and help their individual development. These are outlines, and circumstances, such as hospital visits, service user wishes on the day, may change these. This was seen to happen when one service user was taken to hospital as a precautionary check after a minor injury. The service user later returned to the home, fit and well, and was able to pursue the planned afternoon activity. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Staff continue to work to ensure that the complex needs and challenges presented by the people living at 26 Willes Road do not unduly prevent them from enjoying activities in the wider community. EVIDENCE: Observation of service users showed that activities were taking place in line with the active support plans, including swimming, shopping, and walks. Many activities involve walks into town, the local parks and swimming baths. Comments from another inspector who had recently observed service users out and about in Leamington were very positive. Two service users continue to deliver, with staff support, a weekly newspaper to local households. Staff commented that the two people continue to enjoy this, with one person insisting on continuing last week in heavy rain. This commitment had been observed on a previous inspection. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 12 One service user expressed his interest in helicopters and fairs. The staff member with him was able to amplify this, speaking knowledgeably of how he had enjoyed activities relating to these. Family contacts are maintained and promoted. Two service users spoke of ‘home’ and ‘mum’ positively. One service user is going to Spain for a holiday with staff, where he will also meet up with his parents holidaying there. Service users were offered opportunities to do a variety of activities. Sometimes, staff advised, they are reluctant to do particular activities at particular times, and beyond prompting and encouragement where appropriate, this is accepted. Records show where service users have not wished to do particular activities, such as going out. During this inspection, service users were keen to go out. Regulation 37 notices, informing the Commission of incidents affecting the well-being of service users, frequently concern incidents occurring in the community, and as such, show the continuing commitment of the service to integrate service users in the wider community. The agency manager had queried whether he should continue to send these, as incidents, although often apparently alarming to those outside the home, were often ‘routine’ for those at the home. He was instructed to continue sending them whenever they constituted an incident detrimental to the well-being of the service user. Menus are planned with individual wishes and needs in mind, within an overall context of healthy and varied eating. Service users were seen to be involved in the preparation of food. Pictures of food have been developed, in a folder, and also on the wall, to help service users in making and comprehending choices. Staff commented on the questionable value of the pictures on the wall, owing to their small size and inaccessibility – behind the kitchen door at present and preferred using pictures in the prepared folder as an aid, and hoped to improve on the pictures on the wall. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home continues to strive to support service users’ complex needs in a way that they prefer and require. Service users are generally well-served by the home’s medication procedures and policies, although these need to be more thoroughly followed in some instances, as detailed below, to ensure full protection. EVIDENCE: Much of the support provided consists of helping service users in developing their skills in communication, social and living skills. Written and photographic communication guidance helps manage behaviours that may otherwise limit their social and skills development Staff were able to discuss knowledgeably individual support needs and how these were met. Staff were seen to interact positively and supportively with service users, being aware of, and attentive to, their emotional and health needs. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 14 An example was witnessed of a service user being taken to hospital as a precaution, following an incident of self-injury in the home. The service user later returned and happily carried on with the rest of her day. Other incidents noted in the home were seen to have been managed and recorded appropriately. Health Action Plans were seen. One service user was awaiting an operation, after staff had followed up concerns they had regarding his health. One staff member advised that a service user’s limited vocabulary had extended to include a few additional words, which he was heard to use. These were in connection with things he enjoyed doing, demonstrating the beneficial effects of activities he enjoyed doing. Medication was seen to be recorded and dispensed accurately, with administration helped by brief informative details, including photographs, of individual service user medication needs. The recording of ‘as required’ medication was not clear, with staff apparently recording ‘f;’ when not given, without it being defined what ‘f’ stood for. The system for recording stock for ‘as required’ medication was not clear, particularly in the case of liquid medication. The manager advised that he would review this, as a priority. There is no suspicion that these have been administered or recorded wrongly; but the manager agreed that the present practice must be clearer. A Medication Administration Recording Sheet had been taken from the folder by a member of staff and had been left out in the lounge area. The manager ensured it was put back appropriately. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Staff work hard to support service users to make their views heard and acted upon. The fact that the home has been subject to a number of allegations and vulnerable adult investigations in recent years may be a positive reflection on the willingness of individuals to report concerns, but it is also worrying that such concerns persist. The complex needs of service users makes them particularly vulnerable, and also increases the likelihood of vulnerable adult issues arising. The isolated instance of a staff member observed holding a service user’s wrist raises concerns as to whether training and guidance has been properly taken on by all staff. EVIDENCE: Service users have high communication needs and are dependent to a high degree on staff interpreting their views and wishes, using their knowledge, experience, and existing communication guides. Service users are able to make their views known with a mixture of gestures, one word responses, and in one instance, with a ‘light writer’ device – a light weight, portable, speaking typewriter. Staff were observed to respond to views and wishes. The manager advised that there are service user forums but that these are being rethought, as they have not been very successful. He advised that key worker meetings have been more successful, whereby key workers discuss matters of importance to service users, either raised by them or on their behalf. Service users are able to attend these meetings, records of which were seen, as they wish. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 16 There has been a history of Vulnerable Adult issues at the home over the past few years, and staff are very aware of whistle-blowing and issues of abuse, with a number of staff having either made allegations in the past, or been the subject of them. At present, the manager of the home is under suspension, whilst allegations are being investigated. These allegations centre on staff, rather than service users. The organisation’s investigations of allegations in the recent past have so far shown themselves to be thorough. No complaints have been received concerning the service since the last inspection. One service user self-harms. Policies and procedures, of which staff showed awareness, continue to be in place, including additional staffing for this person. Individual staff practice observed with service users was excellent, with one exception, where a staff member was seen to be potentially over-physical in holding a service user’s wrist. This was discussed with the manager, who agreed it was inappropriate, and has since confirmed that appropriate action is being taken. Service users finances are managed for them; procedures were observed and seen to be open and transparent, with outside auditing taking place. An outside auditor last checked finances, in November, and found them satisfactory, making a number of recommendations, which are being implemented, the deputy service manager later advised. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,30 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. There has been a great deal of improvement evident over the past year or so, resulting in the environment being safer and more attractive. Service users’ safety and well-being will benefit from further improvements. EVIDENCE: The environment is much improved, with redecoration in the lounge and dining room making them much brighter and lighter. Abstract paintings in the dining room, done by staff and service users together, are an impressive new feature. The carpets still require replacing in the lounge and the sensory room. The ‘sensory’ room cannot yet be fully regarded as such. Although much improved from the time it was a general storage room, with lights and music, this room still houses the medication, as well as a notice board, and during the inspection, had washing on a clothes horse, all of which limits its effectiveness as a sensory room. Bedrooms are personalised; improvements continue. During the inspection, one was having a new carpet fitted, and another had a suitable tap installed on a hand wash basin. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 18 The wooden floor of one service user’s bedroom still requires attention, as the varnish has worn off in some areas, exposing bare wood. Staff pointed out the poor state of one service user’s bed during the inspection; the manager agreed that this needed replacing. There had been a flood in the laundry area, which is on the second floor and overhangs the rear of the building, resulting in the outside area below it being considered unsafe. No-one was clear how unsafe it was. Staff were unclear whether the whole floor was in danger of collapsing, or whether just the plaster might fall in. Consequently, an estates manager was called in during the inspection, who, a member of staff informed me, had declared the structure sound, but that the plaster needed replacing and that a builder would visit that day to arrange this. He had not visited by the end of the inspection; the manager advised that he would pursue this. A cordon blocking off the affected area remained in place. The unsafe wooden fire escape to the back garden has been replaced by a much better metal one. The garden has a swing, which the manager advised is frequently used by service users. Some parts of the garden are overgrown. ‘Kickboards’ (panelling at the bottom of a cupboard) in the kitchen were broken. The basement area has been much improved, with a renovated bathroom. It was observed that there was no toilet roll in one toilet, and staff had difficulty in locating any. Three extractor fans, one in the kitchen, and two in bathrooms, were not working. The home was clean throughout during this inspection, and there were no unpleasant odours, save for the faint smell of damp in the lounge area of the basement. It was noted that rainwater drains from the front guttering straight into cemented ground by the basement. The manager was unclear if these then properly drain away from the premises, but advised he would query this. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Staffing is sufficient to enable service users to have individual attention. Service users are benefiting from more consistent and familiar staffing. Shortcomings in staff practice in some areas detract from the excellence of it in other areas. Sound recruitment procedures are compromised by incomplete evidence of Criminal Record Bureau checks. EVIDENCE: There was sufficient staff on duty to meet identified individual needs; four service users have 1:1 staffing, and one service user currently has two staff to ensure his needs are met. A key worker system was in operation, with staff being clear about their responsibilities for individual service users. Good practice and the following of guidelines and training was observed taking place in many instances. There are now more permanent, contracted staff, with consequently less reliance on agency staff. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 20 Examination of staff records, discussion with staff and the agency manager, and examination of a staff training matrix with the agency manager showed that staff received a variety of training designed to equip them to meet and support the needs of people living at 26 Willes Road. All staff had recently had ‘Timian’ training, designed to assist in the management of aggressive challenging behaviour. Staff spoken to were generally enthusiastic about training; one staff had recently completed LDAF (Learning Disability Award Framework) training and was hopeful of pursuing NVQ (National Vocational Qualification) training, something that she said she had not managed in fifteen years in other care work. Three incidents noted during the inspection, and recorded elsewhere, indicate that guidance and training is not being adhered to by all staff: the leaving out of a medication sheet, the holding of a service user by the wrist, and the record of the unsafe presence in the home of a small bottle of concentrated washing up liquid. Recruitment records were seen. In a number of these, details of Criminal Records Bureau Checks were not present. The service manager was later spoken to and advised that these had been done, and that the details would be transferred from the administrative office and included on individual files within the home. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 21 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): 37,39,42 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Unless the issue of the permanent management of the home is resolved fairly speedily, the home risks losing the sense of purpose and direction that it was previously benefiting from. The service tries to safely support vulnerable service users with complex needs whilst maintaining an open, non-institutional environment. To fully protect service users, it must be more vigilant in areas of health and safety. EVIDENCE: The registered manager is currently suspended, following allegations made by staff. These allegations are not seen to have directly impacted upon service users. An agency manager has been in post for less than a month, supported by an acting deputy manager. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 22 No comment cards were received from relatives or service users as part of this inspection. Comment cards received prior to the previous inspection had been positive. One staff member advised that one service user’s relatives, although generally positive, had remarked that they were not informed when a longstanding key worker for their son had left, and felt that they should have been, because of the potential impact on his well-being. Regular and thorough regulation 26 visits take place, records of which highlight the strengths of the service, as well as areas in which it needs to improve. Service user forums have taken place, with staff support, as well as key worker meetings, all of which are aimed at highlighting service user concerns. A staff member was able to give examples of service users’ expressed wishes, principally around more trips out, which they are now striving to meet. An incident had just been reported whereby a service user had come into the office and picked up a small plastic bottle containing concentrated washing-up liquid and swigged it before anyone could prevent him. He was taken to hospital, but no ill-effects were reported. No-one could explain the presence of this bottle, which was not a service purchase. The manager advised that he is investigating this matter and will take action to prevent its recurrence. COSHH (Control of Substances Hazardous to Health) documentation was seen to be in place for all such items purchased by the service, which were stored appropriately. A selection of sharp knives were seen in a kitchen drawer. Although there had been no incidents regarding the misuse of these, the manager agreed that the challenges presented by service users made safer storage desirable, and had them moved. Records of fire drills were seen; staff were able to speak knowledgably of fire procedures, which are now safer following the installation of the new fire escape. The closure device on the kitchen door kept releasing the door prematurely. The manager agreed that a magnetic closure would be preferable. The visitor’s book is kept high up in the hall, to stop it being damaged, I was advised. I was the first to sign it for several weeks. The manager agreed that it needed to be more accessible, whilst remaining safe from removal or damage. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 23 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 X 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 2 25 2 26 3 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 4 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 3 x x 2 x 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 24 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 Requirement The procedure and practice for recording ‘as required’ medication must be clarified, as must stock control for these medications. Medication Administration Records Sheets must remain in the relevant folder and be kept securely at all times. Carpeting in the lounge and ‘sensory’ room requires replacing. The plaster on the outdoor section of the annexe must be made good. Floor level panelling in the kitchen must be repaired or replaced. A new bed is required for a service user in the basement. The garden requires attention. There must be toilet rolls in toilets at all times. An audit is required of extractor fans. Details of satisfactory CRB checks for all staff must be available in the home. A permanent registered manager must be in post DS0000058002.V303761.R01.S.doc Timescale for action 20/08/06 2. YA20 13 20/09/06 3. 4. 5. 6. 7. 8. 9. 10.. 11. YA24 YA24 YA24 YA25 YA24 YA27 YA27 YA34 YA37 23 23 23 23 23 23 23 19 9 20/08/06 20/08/06 20/08/06 20/08/06 20/08/06 20/08/06 20/08/06 20/08/06 20/10/06 26 Willes Road Version 5.2 Page 25 12. 13. 14. YA42 YA42 YA42 23 23 23 Sharp knives must be safely stored and risk assessed. Refresher training on the Control of Substances Hazardous to Health is required. The closure device on the kitchen door requires attention, or replacement. 20/08/06 20/09/06 20/08/06 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 4 5 Refer to Standard YA6 YA24 YA42 YA24 YA39 Good Practice Recommendations It is recommended that information in personal folders also include a specific review date. The sensory room should be devoted to its primary aim. The visitors’ book should be more accessible to facilitate its use. It is recommended that the service checks that the system whereby rainwater from guttering is carried away does not contribute towards the dampness in the basement. Where changes in staff that might impact upon any particular service user it is recommended that the service informs any relatives concerned. 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 26 Willes Road DS0000058002.V303761.R01.S.doc Version 5.2 Page 27 - 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!