Inspection on 23/11/05 for Wings

This inspection was carried out on 23rd November 2005.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wings 01/02/07

Wings 06/04/06

Wings 18/08/05

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 Wings 17 The Grove Beck Row Mildenhall Suffolk IP28 8DP Lead Inspector Deborah Seddon Unannounced Inspection 23rd November 2005 10:00 Wings DS0000063585.V259276.R01.S.doc Version 5.0 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 Wings DS0000063585.V259276.R01.S.doc Version 5.0 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. Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wings Address 17 The Grove Beck Row Mildenhall Suffolk IP28 8DP 01638 583934 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) Compass Care Limited Mrs Joy Sonia Bentley Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person falling within the category of MD, Mentla Disorder excluding Learning Disability or Dementia, may be admitted into the home unless that person also falls within the category LD, Learning Disability is Dual Disability. 18th August 2005 Date of last inspection Brief Description of the Service: Wings is registered as a Care Home for 6 younger people with learning disability and mental health needs, and offers placements to individuals with challenging behaviour. The home is situated on a private road in Beck Row, near to Mildenhall air base. The location is semi-rural and transport is provided by the homes three vehicles to access local facilities. Parking is available at the front of the building. The bungalow offers six individual bedrooms. At one end the building there is a living room, while at the other end the dining room has recently had a dividing wall erected to provide a private and quiet area for service users and staff. The Managers office is situated at the front of the home next to a garage. The fenced garden is mainly grass, but has a patio area and vegetable/flower patch maintained by people living in the home. Wings is owned and run by Compass Care, although Compass Care is owned by Tracs Ltd.. Joy Bentley is the registered care manager. Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over five and a half hours during a weekday. A tour of the premises was made accompanied by a senior member of the staff team. Time was spent with the manager and three staff individually and a number of records were examined including those relating to service users, staff and a selection of policies and procedures. There are currently five service users living at the bungalow. On the day of the inspection two of the service users were at day care facilities. The inspector spent time with one service user who was at home. What the service does well: What has improved since the last inspection? What they could do better: The home needs to continue with the improvements they have already made with regards to the décor of the home, paying particular attention to items like shower rails, slip mats and grab rails where there is a risk of infection occurring. Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 6 Equipment used in the home must be assessed by an appropriately qualified person to ensure that service users have the correct aids, adaptations and equipment to meet their needs. The use of physical restraint in the form of bedrails must be managed through the risk assessment process and the service users consent obtained. All staff needs to attend refresher training in the protection of vulnerable adults which must include the process of reporting and who should be notified in the event of an allegation of abuse being made in the absence of the manager. 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. Wings DS0000063585.V259276.R01.S.doc Version 5.0 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 Wings DS0000063585.V259276.R01.S.doc Version 5.0 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): 1, 2, 4, 5, Prospective service users can expect to have a full assessment made of their needs and detailed information about the home before making a decision about living there. The written licence and tenancy agreement between service users and the home needs to be updated to reflect ownership of the home and the current fees. EVIDENCE: The home has a statement of purpose and service user guide; these are both well presented and offer a lot of detailed information for prospective service users, however the statement of purpose had not been updated to reflect the changes within the company. Compass Care had converted to a limited company and has since been acquired by Tracs Limited. The name and address of the previous partners of Compass Care were still included in the statement of purpose and the registered manager was still showing as the acting manager. The relevant changes have been made to the statement of purpose and have been forwarded to the Commission for Social Care Inspection (CSCI) since the inspection. Wings is registered for six service users, currently there are five service users living at the home. One service user had been supported to move out into independent living accommodation. The manager explained the difficulties in filling the vacancy around the compatibility of a new service user moving into an established service user group. Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 9 The home has a very detailed admissions criteria, which is set out in five stages of referral, assessment, a consultation to discuss if the home can meet the service users needs, a trial visit and admission. One service user’s care plan seen showed that the individual placement contract (IPC) referred to Compass Care Ltd as the proprietors. The service user contract seen was in a suitable format using pictorial aids and had been signed by the service user, however the contract had not been updated since September 2003 to reflect the service users current fee. Wings DS0000063585.V259276.R01.S.doc Version 5.0 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, 8, 9, Service users can expect that their care plan will identify their needs and that they will be supported to make decisions about their life. Service users can expect to receive professional support which will identify behavioural management plans and what support they require, however a risk assessment framework needs to be developed including the use bedsides and restraint. EVIDENCE: Two care plans were looked at during the inspection. Each of the care plans consisted of details covering the emotional, social and personal needs of the residents. Within the service users plan individual care plan sheets have been set to address each activity detailing the support required by staff and the goals to be achieved by the service user. Evidence was seen that care plans have been reviewed with the service users input on a regular monthly basis. Evidence was seen that annual reviews were being held with the service user, social worker, manager and key worker where the service users care needs were discussed and reviewed. A new format for the care plans is in the process of being implemented based on using the person centred approach. Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 11 The home has an established support network with the psychologist and clinical nurse based in Haverhill. They support the home through staff training and assisting in the development of behavioural plans for each of the service users. The behavioural plans set out the danger areas and avoidance strategies for staff guidance and to provide a consistent approach when supporting the service user. One service user has a structured routine in place to meet their needs. This routine allows the resident to make choices how they spend their time. Side effects of the service user’s prescribed medication makes them very sleepy. The structured routine enables them to experience quality time as well as having rest periods. The inspector observed this routine being implemented during the inspection, the service user had been supported to get up, shower and have a cigarette. According to the resident’s routine they had recorded that they wanted to go out for lunch, however the service user decided to stay at home. The inspector was informed that service users and staff have regular house meetings on a Sunday lunchtime where they discuss what has happened during the week and what will be happening in the coming week. Discussions also take place about outings, holidays, Christmas activities, trips out, and decoration to the home. During a tour of the home, the inspector noticed that one service user had bedsides fitted to their bed. The senior carer informed the inspector that the service user had a weight issue and the rails had been fitted to prevent them falling and getting out of bed at night. The service user also used them to hold onto when staff attend to their personal care needs. Discussion took place with the senior and the manager about the use of bedsides as a method of restraint and that their use needs to be fully explored through a risk assessment framework and service users consent obtained. The manager informed the inspector that they are in the process of reviewing health and safety and all risk assessments in the home and would include the use of bedrails. Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 12 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): 11, 12, 13, 14, 15, 16, 17, Service users can expect that they will be supported to take part in appropriate activities within the local community and have the opportunity to mix with other adults. EVIDENCE: The home accesses a local college that provides a tutor to visit the home to undertake art and craft sessions once a week and also have access to other specialised day care services. One service user attends The Barns autistic centre where they do a lot of work around improving their communication. The TEACH system is used to encourage the service users communication skills focusing on positive speech and reducing repetitiveness of sentences and persistence of questioning. Two service users were attending a day care service called Woodenstuff. This is a unit in Bury St Edmunds where residents are supported to make items and paint. The inspector saw samples of some of the paintings and objects made by one of the service users in their room. The service users are to attend a Christmas party at Woodenstuff centre on the 6th December. Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 13 Onward enterprise factory in Thetford provides an opportunity for supported work placements for up to four people with learning disabilities, which involves packing palettes; two of the service users from Wings attend on a Thursday and Friday. Service users are involved in a range of activities including going to the pubs and shopping enabling them to participate in the local community, this was confirmed in discussion with one of the service users and was referred to in the service users care plan. One of the service users has become a wellknown member of the congregation of a local church used by the American air base. The service user attends regularly every two to three weeks. The air base has extended an invitation to the service users living at Wings to join a Christmas party on the air base. Two service users generally attend Gateway club on a Thursday evening, where they are able to join in activities and have the opportunity to mix with other people. Activities throughout the year have included bingo, game show night, fish and chip supper, mastermind, bowling, spooky disco and an indoor sports tournament. Most recently service users have been making Christmas crafts. Other activities arranged by the home include a trip to the Pantomime ‘Cinderella’ in Hunstanton on the 23rd December. All the service users have decided to go and will be accompanied by six staff. One service user who did not want to watch the pantomime has decided to still go on the trip and will spend time with a member of staff enjoying a drink in the bar. The inspector spent time talking with one of the service users who told them they were going Christmas shopping in Milton Keynes. They were observed making plans with a member of staff about the shopping trip and how much money they needed to do their shopping and have lunch out. They spoke of “I like living here and I have freedom that I did not have in my previous home and nice staff work here” and “food is good”. They told the inspector that they sometimes go to a befriending centre in Bury St Edmunds and liked going to car boot sales but preferred to spend most of their time at home enjoying their hobby of cross-stitching, rug making and knitting. This service user receives the higher rate of mobility and is being supported to purchase their own car, to encourage them to access the community more often. They also told the inspector they had been to Great Yarmouth for a summer holiday and had also enjoyed days out to Brighton and Hunstanton. Service users are encouraged to take part in the daily routine of the home. A chore board was seen on display in the hallway. Service users decide on which chore they are going to be responsible for during the week and apply a pictorial symbol of that chore on the board. At the end of the week service users and staff have a meeting to compare and praise who has completed the most chores. Service users are offered a choice of food; the choice of meals was written on a board in the kitchen. One service user requested plain chicken and a jacket potato; two service users had chosen chicken curry and another had chosen a vegetable curry. One service user was observed making their own sandwich for their lunch. Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 14 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, 21, Service users can expect to have their personal and physical needs met and have good access to specialist and healthcare services. Service users wishes are respected in the event of deterioration in health, dying and death. EVIDENCE: Each service user has a care plan sheet which identifies their needs and what support they require. The plans include detailed instructions on their daily routines according to their preferences and individual choices. Behavioural management plans are in place for each service user, and focus on the danger areas that trigger the service users behaviour and avoidance strategies. The home receives a lot of support from a psychologist and clinical nurse who specialise in behaviour management. A full assessment of the service users has been undertaken identifying triggers for their behaviour, including how staff need to respond to diffuse and manage the situation for two service users that have the potential to self-harm. All incidents are recorded and the service users behaviour monitored. Evidence was seen on both care plans looked at the service users have access to health professionals as required. There were regular entries of appointments to the general practitioner (GP), chiropodist, hospital and physiotherapist. Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 15 One service user’s plan showed that they were having their weight monitored regularly and had received input from their GP and a physiotherapist to devise a plan to build up their muscles through an exercise plan to achieve their goal to walk. Staff were observed supporting the service user to transfer from their armchair to wheelchair in accordance with the details set out in their care plan. Evidence was seen in one of the service user’s care plans of a detailed description of how they wished the home to support them, as they grow older and in the events that their health deteriorated or becoming terminally ill. They had discussed all the issues with the manager, their key worker and social worker. Their wishes were to stay at the home, as they grow older and accepted that they if their health changed they may have to have more support to meet their care needs. They accepted that if they became terminally ill that they would need to go into hospital for treatment, and that they may be able to return home for nursing and palliative care. The plan also took into account their wishes in the event of their death, stating that they wished to be cremated and have their ashes buried with their relative, and wanted all their belongings to go to charity. Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 16 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): 23 The home has a clear policy and procedure in place for dealing with allegations or suspicions of abuse, however staff need to have training to ensure that they are aware of the procedures involved in reporting abuse. EVIDENCE: Wings have a detailed company policy in place setting out clear guidelines for the protection of vulnerable adults and dealing with allegations of abuse, however staff spoken with during the inspection were not fully aware of the procedure to follow and who to contact if an allegation of abuse was made in the absence of the manager. A copy of the Suffolk vulnerable adults protection committee (VAPC) inter agency policy and referral forms are held in the managers office. Through discussion with the manager a leaflet about the VAPC will be placed in the staff base to give staff guidance of who to contact including the customer 1st team and the Commission for Social Care Inspection (CSCI). Staff had not received recent updated training in the protection of vulnerable adults. Wings DS0000063585.V259276.R01.S.doc Version 5.0 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, 26, 27, 28, 29, Service users can expect to live in a home that meets their needs in a safe and welcoming homely atmosphere, which provides a good range of personal and communal space. Aids, adaptations and equipment provided for service users needs to be assessed by an occupational therapist or suitably qualified specialist. EVIDENCE: Wings is a six bedded bungalow purpose built and has a central corridor running the full length of the building allowing easy access to all communal areas and bedrooms. The home has two lounge/diners, a kitchen, two shower rooms and one bathroom and a utility room. The home is set on the edge of Mildenhall close to the air base and benefits from being close to local amenities such as shops, pubs, a post office and a fish and chip shop. These are all within a short distance from the home. The premises have undergone a programme of redecoration and is looking comfortable, bright and cheery, however it was noted that the curtain rail in one of the shower rooms was rusting and needed replacing. The slip mat used when stepping out of the shower was looking warn and dirty and had not been lifted after use for cleaning and presented a hygiene risk. The grab rail was very dirty and covered with paint following the recent decoration. Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 18 There was a broken light fitting in the bathroom which the inspector was informed is in the process of being replaced. The service users all have their own bedroom; these were seen during the inspection and were decorated to reflect the individual’s personal tastes, age appropriate and personalities. Service users had their own items of furniture and personal televisions and musical equipment in their bedrooms, they also have access to television, videos and musical equipment in the main lounge. The kitchen was observed being used as a walkway through to the manager’s office, which is situated to the front of the building. The manager informed the inspector that this issue has been raised by the environmental health service and consideration needs to be given to an alternative route. The boilers and heating system were being replaced on the day of the inspection and it was therefore not possible to see the utility room, once the heating system has been replaced the inspector was informed that further decoration to the utility area and the home is scheduled. All radiators in the home have been fitted with handmade radiator covers. One of the service user’s had been provided with a standing frame to help with their personal care and had a commode chair adapted to meet their needs. The adaptation had been carried out on the recommendations of member of staff and had been welded so that the arm could be removed and replaced as required. Although the adaptation worked well for the service user there is an issue around health and safety and the suitability of the piece of equipment if an accident occurred. The inspector discussed with the member of staff that the commode looked unsightly like it was rusting where the welding had been done and needed some attention. Wings DS0000063585.V259276.R01.S.doc Version 5.0 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, 33, 34, 35, Service users can expect to be cared for by a staff team who are supported and available in sufficient numbers to meet service users needs. EVIDENCE: The staff rota was seen and reflected the number of staff on duty. There were six staff working between the hours of 7.30am to 10pm. Staff work flexible hours to meet the needs of the service users within their contracted hours. There were three to four staff on the premises throughout the day. There are two night staff who work between the hours to 10pm to 8am. Staff were observed interacting positively with service users throughout the inspection and in an appropriate manner. The inspector was able to speak with three staff individually and as part of a group. The majority of the staff have worked at the home since it opened and provide service users with a stable staff team. Staff spoke of a difficult period involving the suspension and dismissal of a colleague, which had affected staff morale, however they feel that they were well supported by the manager and the staff are now working better as a team. Staff files seen demonstrated that the home had the necessary checks in place for the safe recruitment of staff, including a criminal records bureau check (CRB) and other relevant documents. Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 20 All staff have received training from Unisafe and studio 3 training. The course promotes different techniques for dealing with service users on a daily basis and is designed to lower residents arousal and anxieties. A programme of staff training was seen displayed on the notice board in the staff base, recent training has included medication, this is a 14-week long distance learning course. Three staff have been scheduled to complete the Boots monitored dosage system training (MDS) however a date is to be arranged. There have been sessions for Autism training over a three-week period. All staff are scheduled to complete a food hygiene course on the 8th December and moving and handling training on the 28th and 29th November 2005. In addition to the core training four staff have achieved national vocational qualifications (NVQ) at level 3 and one member of staff is working towards completion. The manager received confirmation during the inspection that West Suffolk College has five spaces for staff to enrol to undertake NVQ 3. Wings employ sixteen staff in total including the manager and will have 50 of staff working towards or trained at NVQ standard by the end of 2005. Two staff spoken with informed the inspector that they had also completed the learning and development framework (LDAF). The manager has completed their NVQ 4 and the registered managers award (RMA) and has commenced the certificate in management studies at West Suffolk College. Wings DS0000063585.V259276.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not inspected on this occasion; the key standards, 37,39 and 42 were inspected at the last inspection in August 2005. Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X 3 2 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 3 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wings Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000063585.V259276.R01.S.doc Version 5.0 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5 (b)(c) Requirement The individual placement contract (IPC) needs to be updated to reflect current fee between the service user and Compass Care. Where the use of bedrails are used as a form of restraint, the use of physical restraint of this kind is the only practicable means of securing the welfare of that service user, the circumstances must be recorded and managed as part of a risk assessment framework and the service users consent obtained. All staff must receive adult protection training and guidance on the procedure for referring allegations of abuse. Consideration must be given to finding an alternative route to the manager’s office other than through the kitchen as raised by the environmental health. An ongoing schedule of maintenance and decoration to include the replacement shower DS0000063585.V259276.R01.S.doc Timescale for action 06/01/06 2. YA9 13 (7) (8) 23/12/05 3. YA23 13 (6) 31/01/06 4. YA24 23 31/03/06 4. YA24 23 (d) 23/12/05 Wings Version 5.0 Page 24 5. YA29 23 (c) (n) rail, light fittings and slip matt. Arrangements to be made to keep slip matt and grab rails clean. Where service users are provided 31/01/06 with aids, adaptations and equipment these must be assessed by an occupational therapist or suitably qualified specialist to ensure that the equipment meets the needs of the service user and comply with health and safety. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Wings DS0000063585.V259276.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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