Inspection on 08/02/07 for William Morris House

This inspection was carried out on 8th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

William Morris House 14/11/05

William Morris House 04/07/05

William Morris House 01/02/05

William Morris House 17/06/04

William Morris House 19/11/03

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 William Morris House William Morris House Eastington Stonehouse Glos GL10 3SH Lead Inspector Mr Paul Chapman Key Unannounced Inspection 08/02/07 09:30 William Morris House DS0000016648.V303592.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 William Morris House DS0000016648.V303592.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. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service William Morris House Address William Morris House Eastington Stonehouse Glos GL10 3SH 01453 824025 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) William Morris Camphill Community Suzanne Pickering Care Home 35 Category(ies) of Learning disability (35) registration, with number of places William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2005 Brief Description of the Service: William Morris House (WMH) named after the designer, craftsman and author William Morris (1834-1896) is part of the International Camphill Movement, founded in 1940. The Home is one of thirty Camphill Communities in Britain. The movement is inspired by teachings of the late philosopher and teacher Rudolf Steiner. It is dedicated to serving the needs of young people with learning disabilities, aged between sixteen and twenty five years during their transition to adulthood. WMH is also a registered residential care home. It provides education in a residential college setting, which is subject to OFSTED Inspection. The home is situated in Eastington, which is approximately 3 miles from Stroud town centre and is within a few minutes from J13 of the M5. The campus is set in countryside and consists of four households, surrounded by gardens and other workshop buildings. The four houses function as extended families with Students and carers living and socialising together. The first three years have a strong educational element alongside social therapy, where students attend the college on site, for thirty-seven weeks of the year. From nineteen years onwards the student becomes a trainee and the emphasis is on work related skills for a period of forty-three weeks in a year. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prospective students are provided with a Service User’s Guide as part of the assessment process. In addition to this they will be invited to visit and spend time at the home as part of the assessment process. Fees range from £600.00 to £1780.00 per week. This unannounced inspection took place over seven hours on a day in February 2007. The inspector joined a group of students for lunch, and after this met with eleven other students to discuss their thoughts about living at the home. Six members of staff were spoken to as a group; other staff were spoken with during the day as the inspector came into contact with them. A tour of the premises and grounds was conducted. The assessment process for four prospective students was examined in detail as well as the care of four current students. Other records examined included students’ files, health and safety records and policies and procedures. What the service does well: What has improved since the last inspection? The service has continued to develop since the implementation of the National Minimum standards in April 2002, and this is reflected in the reports. This inspection has shown the manager has continued this progress. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 6 Parents are asked to complete surveys about the quality of the service provided at the home. Examination of the survey completed in January 2007 showed parents were very positive about the service provided. Over 50 of the house parents now have a minimum of NVQ level 3 in care and other house parents are about to start theirs. 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. William Morris House DS0000016648.V303592.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 William Morris House DS0000016648.V303592.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective students are thoroughly assessed before they are offered a place to minimise the risk of people being admitted to the service whose needs cannot be met. EVIDENCE: Assessments for three of the prospective students were examined in detail. They showed that each person completed an application form providing a detailed personal history. This forms the first part of the home’s assessment process. After the initial assessment people are invited to visit William Morris House where the assessment will continue. An educational assessment is completed by the education co-ordinator (in addition to the home being regulated by the CSCI the educational side is overseen by Ofsted). As part of the assessment process all of the tutors who work with the student on that day are asked to give their views from their involvement with the prospective student. This also forms part of the overall assessment. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 9 To support all assessments completed by William Morris House they receive assessment/reports from social workers or previous educational establishments. In addition to this they will also have reports from other professionals involved in the prospective students care, for example speech and language therapists. Correspondence to the prospective student and their care managers were evident in the student’s files confirming their placement at William Morris House. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 10 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. This judgement has been made using available evidence including a visit to this service. Assessments completed by the House parents allow the students to be supported appropriately to meet their identified needs. Individual learning plans ensure that staff can monitor, review and report on the students progress towards their goals accurately. Potential risks to the students are identified and minimised where possible. EVIDENCE: William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 11 House parents complete a skills assessment during a student’s first term. The assessment is very comprehensive and identifies the areas of personal hygiene, eating, health, preparing and cooking food/drinks, laying a table, washing up, looking after a room, public transport, local knowledge, shopping, communication, social conduct and telephone skills. Records seen of these assessments showed them to be regularly recorded and allowed the reader to see the progress of a student at a glance. House parents then review these assessments every six months. All of the examples examined showed that the house parents had completed reviews of the skills assessments. A shortfall identified related to one review where the house parent had answered “yes” and “no” to questions rather than provide detail of actually what the student had achieved. This was brought to the attention of the staff supporting the inspector. This must be addressed by the manager to ensure that students’ needs continue to be met. Each student has Individual Learning and Care plan assessments that comprise of a student profile, care plan and an individual learning plan. This allows the staff to identify goals with the students and reports and reviews are completed twice during the first two terms. The assessment process is comprehensive and enables the staff to agree targets for skill improvements with the students. Once these targets have been agreed the house parents are responsible for supporting the student to achieve them. As part of the site visit the inspector met with eleven of the current students as a group. Various topics were discussed. Students were asked whether friends and family are welcome to come and visit them. All of the students agreed that this was alright and gave examples. In addition to this they spoke about other ways they are able to communicate with others outside. They gave examples of using emails, telephone and writing letters. Talking to students about their lifestyles they gave examples about making decisions about activities in the local community that they like to take part in. All students have “life books”. These are created by the student with the support of staff. They make good use of pictures with descriptions to document the activities students take part in during their time at William Morris House. Five life books were sampled. The manager stated that students take the books home during their holidays so parents can see what the students have been doing. The manager stated that they have asked parents to complete the life books whilst students are at home so the staff can see what the student has been doing during their holiday. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 12 Staff at the home have completed risk assessments for all of the students. These assessments are comprehensive and empower the students to complete activities. All of the students’ documents are stored securely. William Morris House DS0000016648.V303592.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 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. This judgement has been made using available evidence including a visit to this service. The home provides the students with varied and fulfilling lifestyles that meet their needs. The food served across the site is healthy and nutritious and chosen by the students. EVIDENCE: A group of eleven students were spoken with and all gave examples of the various activities they are involved in around the site and in the local community. Some of the activities organised on site each week are a film club, craft evening and folk dancing. Activities in the local community included meals out, the cinema, horse riding, hockey, swimming, bowling and shopping. Students were asked whether there was enough to do and whether they enjoyed the activities they were involved in. All of the students were very William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 14 positive stating that they really enjoyed living at the home. One student commented that the “college is fantastic”. Other comments included it was “fun”, “interesting” and “peaceful”. The home makes good use of facilities in nearby Stroud as well as other towns locally (shopping in Bristol, Cheltenham, Gloucester and Bath). Students attend a “student forum” every other Tuesday where they discuss issues and now publish a student newspaper twice a year called the Sunshine Express. The last edition was published in August 2006 and at the time of this inspection students were busy creating the next publication. As identified earlier in this report students all agreed that their parents/relatives and friends are allowed to visit when they wish. Students are supported to attend a local church if they wish. Students are involved in bible study groups with their house parents one night each week. Staff explained that as well as these groups’ students are given the opportunity to learn about other religions. As identified earlier William Morris House is an educational college and is inspected by OFSTED regularly. It therefore has an obligation to meet the educational needs of the students. Some of the classes organised on site included gardening, weaving and woodwork. The manager explained that each student has a lesson book and that subjects are taught in 3 or 4 week blocks. At the time of this site visit students were studying the world and me, health and diet and astronomy. As well as students attending classes on site students also attend the local college in Stroud to complete courses. The courses accessed by students include drama, music, computers and cooking. Another course used by the older students is called “out and about” and teaches people skills needed to access the community independently. Talking to staff they confirmed that where required they support students at college. Students were enthusiastic about these courses and spoke about what they were learning. Students are supported by staff in the preparation of food. Meals are eaten together in the respective Houses. There is a central food store, from which the individual Houses replenish their provisions. Food is always fresh and predominantly organic. No meals are pre-packaged. Meals are chosen for the week by the students at the Monday house meetings. This maybe someone’s individual choice or a meal may consist of several choices on one plate. Menus confirmed that the students were offered nutritious, varied and balanced meals. Menus showed that the meals were offered three times a day and that there were also a range of snacks available to people. The Inspector joined a group of students for lunch during the inspection. Students and staff sit and eat together promoting family/Community. Students commented that they thought the food provided on site was really nice and that they were able to choose. Across the site the manager is implementing a document called “safer William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 15 food, better business” which was supplied to them by the Environmental Health department. This provides guidance for staff to follow to minimise the risk to people through food preparation and storage. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Students’ personal care needs are identified by the house parents which enables them to meet those needs. Students’ health needs are addressed by access to a local GP whilst they are at William Morris House. Review of some the medication practices will ensure that risks to the students are minimised. EVIDENCE: The house parents or co-workers deal with any personal care requirements. Each student’s personal care needs are assessed and reviewed regularly. Students personal care needs are only attended to by house parents that live with the students. Students’ health needs are met locally with students being registered at a local GP’s surgery. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 17 Medication administration across the site was examined. On the whole this was seen to be being managed correctly by staff. All staff that administer medication have received training. Two shortfalls were identified: • • One house was “re-dispensing” medication and it was explained that this should not happen. Medication must be kept in its original packaging. One house has a fridge where they store medication. Staff must ensure that the temperature is recorded daily and corrective action taken where appropriate. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. Students are empowered to make complaints and feel that if they were unhappy the home would address this appropriately. Interviews conducted with the students showed that there were no concerns raised about their safety whilst at William Morris House. EVIDENCE: William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 19 The home has a complaints procedure and whilst speaking with the students they confirmed that they could make a complaint if they were unhappy about something. Students confirmed that if they made a complaint they felt that it would be dealt with appropriately. Since the previous inspection two complaints have been made to the CSCI by parents of students. Both complaints were returned to the provider to investigate and have now been passed on to the relevant funding authorities to investigate further as complainants were not satisfied with the findings. The findings from one of the investigations completed by the home have identified a breach in regulations and a requirement has been made in this report to address this. The breach of regulations was the home not informing the CSCI of an incident adversely affecting the well being of a student. In addition to the two complaints identified above an allegation was made in November 2006 about a staff member. This led to an independent professional (specialising in the protection of vulnerable adults and children) working with the home’s adult and child protection officer interviewing all of the students. The conclusion of the findings stated that “there were no concerns identified from any of the students relating to co-workers, house parents or staff, no issues raised or implied during the sessions about abuse on any level”. Although no concerns were identified through the interviews with the students, a number of actions were highlighted to be completed that would enhance the protection of the students. One action that has been completed is that all of the students have updated “helping hands” documents. These are kept in their bedrooms and identify important phone numbers that they should call if they are unhappy. In addition to this students have been given the contact details for advocacy groups and Citizens Advice in Gloucestershire. The home has a trained member of staff who is responsible for taking the lead in any issues of adult and child protection. All staff receive training in protection and this is provided by a qualified trainer from Camphill and the trained staff member on site. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 20 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, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes across the site appear to meet the needs of the current students, being nicely decorated and personalised with items of students’ artwork. EVIDENCE: Students are not allowed televisions in their bedrooms, and they are made aware of this before they move into the home. There are four houses within the Community campus, Kelmscott, Bridge, Hiram and Merton. Kelmscott – provides the students with a separate lounge and a dining room. The communal area is a good size and was personalised with the student’s pottery, pictures and carvings. No issues identified. Since the previous inspection a new carpet has been fitted in some areas of the home. Whilst completing a tour of this house a couple of shortfalls were identified: • There was a leak in the roof on the top landing. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 21 • Both toilets should be painted as they were looking a little tired, one needed a new seat and the other did not have any toilet paper. This was brought to the attention of staff. Bridge – students have a separate lounge and dining room, and as with the previous home were decorated by students work. Again the use of signs and symbols was evident and the staff explained that they have input from a speech therapist. It is also planned that a “hearing loop” will be fitted for one student. Hiram – the home was purpose built twelve years ago. It has high ceilings and large windows that give it a light and airy feeling. The accommodation provides a large lounge/diner personalised by the students. The inspector noted a good use of symbols to support students with communication difficulties. Since the previous inspection the kitchen has been re-tiled and a new cooker has been purchased. Merton – provides a lounge/diner on the first floor with bedrooms on the ground floor. Since the previous inspection the hall and landing has been decorated. Willow House - Willow house is a detached property within a short walking distance from the main site. It provides accommodation for up to four students and two staff. Each of the students has their own bedroom and there is a communal dining room and a lounge. The kitchen is well equipped. Students and the staff have made a good job of adding their personal touches, which in turn make it homely and comfortable. At the time of this inspection the home was clean and tidy. Kelmscott, Bridge and Hiram houses would be suitable for wheelchair users, Merton because of its design would not be. The property is set back off a quiet country lane. There is a short walk to the nearest bus stop. The home does have its own transport in the form of cars and mini buses. Each house sets out its refurbishment requirements each year and presents these to the main management group. The manager stated that they plan to have a new central heating system and double glazed windows fitted in the main house. This will be completed over the next two/three years. All of the student’s bedrooms were personalised with their possessions and decorated to a good standard. On the day of this inspection all of the homes across the site were cleaned to a high standard. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 22 William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 23 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, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff training is comprehensive and this enables staff to meet the students’ needs and maintain a safe environment. Documents required as part of the recruitment process were present but greater detail is required to ensure that students are not put at any unnecessary risks. EVIDENCE: All new co-workers complete LDAF (Learning Disability Award Framework). Speaking with staff they said they knew a lot of the information before they completed the training. Training records that were seen showed that new staff had completed an induction period with the appropriate training being provided. Other training records showed that the majority of the team had completed Health and Safety, Equal Opportunities, Confidentiality, Personal Care, First Aid, Medication, Risk Assessment, Makaton, Protection and Prevention of Abuse. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 24 The manager has developed an effective training matrix which identifies the teams training needs. The manager completes an annual audit of training needs for the following 12 months. One house parent has completed a NVQ (National Vocational Qualification) level four in management. Three of the other house parents have completed NVQ level 3’s in care. Three other house parents are due to start their NVQ level 3’s in care in the near future. Talking with house parents that had completed these qualifications they felt completing their NVQ’s had been useful and some people now intend to complete NVQ level 4’s. A sample of recruitment records were examined for staff that have started at the home since the previous inspection. There were a number of examples of the foreign equivalent to a Criminal Records Bureau (CRB) check. The manager explained that they translated by staff on site. The manager must ensure that a record of these translations are kept. In addition to this the manager must ensure that when they are employing staff from other countries that a copy of their passport is kept in their file. Since the previous inspection the manager has developed a “co-workers charter” that defines the terms and conditions for them whilst they are working at the home. Records of supervision sessions with the staff were available. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 25 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 good. This judgement has been made using available evidence including a visit to this service. The manager has substantial experience and qualifications which enable them to manage the home effectively. Parents of the students are asked for their opinions of the service and this forms part of the quality assurance process that enables improvements where required. By completing a health and safety audit and carrying out other regular checks the home ensures risk to students are minimised. EVIDENCE: The manager has been in post for a number of years and has completed the registered managers award. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 26 The manager completes an annual audit of the service. As part of this process parents of the students are sent questionnaires to complete asking about the service provided by the home. The inspector examined a sample of the latest ones that had been returned. All of the responses seen were very positive about the home and the students’ care. The home has a comprehensive health and safety action plan that identifies issues across the site and sets timescales for actions required. The issues are identified through regular audits. Inspection across the site showed that other checks required by health and safety legislation have been completed. These included Portable Appliance Testing (PAT), fridge and freezer temperature monitoring, Use of food probes for cooked meat, fire appliance safety checks and risk assessments. A fire risk assessment for the site has not been completed as yet; two staff have received training and will be completing the assessment in the near future. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 27 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 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 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 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 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 3 X 3 X X 2 X William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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 YA6 Regulation 14(1) a, 15 13(2) Requirement The registered manager must ensure that reviews of the students needs are thoroughly completed by all of the staff. The registered manager must ensure that staff do not “redispense” the students medication. The registered manager must ensure that staff monitor and record the temperatures for the fridge used to store medication. The registered manager must ensure that the CSCI are notified of all incidents relating to regulation 37. The registered manager must ensure that that following shortfalls in Kelmscott house are addressed: • • There was a leak in the roof on the top landing. Both toilets should be painted, as they were looking a little tired, one needed a new seat. 06/04/07 Page 29 Timescale for action 20/04/07 2. YA20 06/04/07 3. YA20 13(2) 06/04/07 4. YA23 37 06/04/07 5. YA24 23(2) b, c, d 29/06/07 6. YA34 7, 9, 19 The registered manager must DS0000016648.V303592.R01.S.doc William Morris House Version 5.2 schedule 2 ensure that translations of the foreign equivalent to the CRB are kept in staff files. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA42 Good Practice Recommendations The staff should ensure that toilet rolls are always available in each toilet. William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 William Morris House DS0000016648.V303592.R01.S.doc Version 5.2 Page 31 - 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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