CARE HOME ADULTS 18-65
Woodmere Lower Wokingham Road Crowthorne Berkshire RG45 6BT Lead Inspector
Marie Carvell Unannounced Inspection 25th January 2007 11:00 DS0000051693.V325367.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 DS0000051693.V325367.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. DS0000051693.V325367.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Woodmere Address Lower Wokingham Road Crowthorne Berkshire RG45 6BT 0118 929 7900 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) www.new-support.org.uk New Support Options Limited Ms Esther Callaghan Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000051693.V325367.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: Woodmere cares for six adults with learning disabilities. It is set in a residential area close to local amenities and the town centre. The home consists of two single flats with lounge, toilet/bathroom and kitchen and two dual shared living quarters. The accommodation that is provided is all within the same building and all of the bedrooms are single occupancy. The home also has its own vehicle to assist the residents with transport, or they can use public transport if preferred. The range of care needs within the home is diverse and complex. Several of the service users have needs, which can challenge the service. The home currently has six service users. The current scale of charges as at January 2007 is £1497.04 per week. There are additional charges for haircuts, toiletries, meals out and some activities. DS0000051693.V325367.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Commission has, since 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘key Inspection’. The inspector arrived at the service at 11am and was in the service until 4.35pm. It was a thorough look at how well the service was doing. It took into account detailed information provided by one of the senior support workers in the absence of the service’s manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection. Six service users and one relative responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standards of the service. A detailed tour of the premises was carried out and a sample of records required to be kept in the home were examined, including case tracking of two service user’s files. At the last inspection carried out in January 2006, one requirement and one recommendation were made, these were that the manager ensures that the medication cabinet is removed from the bathroom and that when recording minutes from service user meetings these are accurate and give a true reflection of what was discussed. These have been complied with. Feedback was given to the manager at the end of the inspection. What the service does well:
There has been one service user admitted to the home since the last inspection. Records seen indicated that a full needs assessment was obtained on the prospective service user prior to admission to the home for a trial period. Following a period of settling in supported by home staff, social care professionals and relatives a meeting took place to decide whether the home was able to meet the service user’s needs. Service user records of the admission and settling in period were comprehensive and well maintained. All service users have a weekly programme of activities. Daily activities undertaken are recorded in service user records. The home has its own vehicle, which is well used for outings. Six service users’ returned their completed questionnaires, with assistance from support staff. Comments made on service user questionnaires included “I sometimes choose to stay in bed longer. Sometimes choose not to go out, choose meals and drinks”, “Sometimes I don’t go out as much as I want because of staff shortages”, “I enjoy watching television and like to go out with someone who supports me. If
DS0000051693.V325367.R01.S.doc Version 5.2 Page 6 I show signs of wanting to go out, people who support me, help me”, “ If I ask for something, this will happen. If I choose not to do something, there is no pressure on me” and “ My room is very tidy and my flat has a cosy, lived in feel”. Service user’s rights and responsibilities are respected and this is evidenced in service user records. The right to be alone is respected by staff, who do not enter bedrooms without permission. Visitors to the home are made welcome. Service user birthdays and other events in the home always include families and friends. Daily routines are relaxed and flexible to meet the service users preferences. From the evidence seen by the inspector and discussion with the manager, the inspector considers that the home would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Service user’s records evidenced that regular healthcare checks take place and that healthcare professionals are in regular contact with service users and the staff team. There is a complaints procedure in place and is available in pictorial format for service users. Comments made on service user questionnaires about making a complaint included “ Talking to staff, key worker or the manager”, “ Tell the staff”. Most service users know who to speak to if unhappy, for some service users this may be expressed through changes in their behaviours. The manager and staff team take complaints seriously and this was evidenced in the three complaints recorded in the complaints book. No information concerning complaints about the service has been received by CSCI since the last inspection. Staff on duty said that the staff team work well together. In discussion with staff and observation it was evident that they are fully aware of the service users wishes and choices. Staff were observed carrying out their duties with patience and humour. When asked staff were knowledgeable about individual care needs and behavioural guidelines in place. What has improved since the last inspection?
Service users are assisted and encouraged to exercise their right to make decisions and choices. At the last inspection a recommendation was made that when recording minutes for service user meetings, the manager should ensure that the minutes are accurate and give a true reflection of what was discussed. The manager confirmed that this recommendation had been acted upon and in addition, the manager joins service users at meal times to seek their views and opinions on a range of subjects. One service user questionnaire completed by a relative stated “X condition does not allow him to make any decisions for
DS0000051693.V325367.R01.S.doc Version 5.2 Page 7 himself and he has a limited life choice, however, decisions are made on his behalf with care”. At the last inspection a requirement was made that the manager must ensure that the medication cabinet is removed from the bathroom as specified by the pharmacist during her previous visits. What they could do better:
Some areas of the home require urgent repair. One identified communal bathroom needs repair or replacement to the floor covering, wall tiles need replacing and the broken toilet seat replacing. In addition a radiator was found to be leaking badly. An area of ceiling was water damaged and needs to be redecorated. Since the last inspection two support workers and one senior support worker has been recruited. However, the home continues to have five or six full time vacancies for support staff and is without a deputy manager. In addition one member of staff is absent from the home on a temporary basis and a second member of staff has taken paternity leave. These hours are covered by existing staff working additional hours or by regular bank staff. The inspector was advised that a staff development and training programme was being developed. From examination of a sample of training records, it was not evidenced that mandatory or specialist training is updated on a regular basis. Training records of one senior support worker showed that Fire Safety had not been updated since December 2001, Health & Safety since February 2002 and Moving & Handling since February 2002. The manager confirmed that training records might not be up to date and need updating to include recent training undertaken by staff. Not all staff are receiving formal supervision on a regular basis. The manager stated that this is extremely difficult to achieve at present, due to staff shortages. From examination of duty rosters and discussion with the manager, it is clear that she frequently has insufficient time to carry out some of her administrative and management responsibilities, due to having to cover shifts on the duty roster by providing direct care to service users. On the day of this visit the manager was working from 9am until 3pm and then working until 10pm covering the evening roster. It is not clear whether a deputy manager is to be recruited to assist with specific areas within the home. A sample of records relating to health, safety and fire were examined. The manager’s attention was drawn to the fact that the last record of a quarterly service and testing of the fire alarm system having being undertaken was March 2006. DS0000051693.V325367.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000051693.V325367.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000051693.V325367.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 4. Quality in this outcome area is good. All service users are assessed prior to moving into the home and are given the opportunity to visit the home and stay for short periods to be clear whether the home meets their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been one service user admitted to the home since the last inspection. Records seen indicated that a full needs assessment was obtained on the prospective service user prior to admission to the home for a trial period. Following a period of settling in supported by home staff, social care professionals and relatives a meeting took place to decide whether the home was able to meet the service user’s needs. Service user records of the admission and settling in period were comprehensive and well maintained. The remaining five service users have lived in the home since it opened in 1998. Previous inspection information indicated that all service users had a full needs assessment undertaken prior to moving into the home. There is a comprehensive referral and admission process in place. DS0000051693.V325367.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7,8 and 9. Standard 8 was subject to a good practice recommendation at the last inspection. Quality in this outcome area is good. Service users have detailed care plans and are involved as much as possible, with decision making. Appropriate risk assessments are in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users have a detailed care plan; these are reviewed on a regular basis and updated as necessary. Service users are enabled to be involved as much as possible. Service users are assisted and encouraged to exercise their right to make decisions and choices. At the last inspection a recommendation was made that when recording minutes for service user meetings, the manager should ensure that the minutes are accurate and give a true reflection of what was discussed.
DS0000051693.V325367.R01.S.doc Version 5.2 Page 12 The manager confirmed that this recommendation had been acted upon and in addition, the manager joins service users at meal times to seek their views and opinions on a range of subjects. One service user questionnaire completed by a relative stated “X condition does not allow him to make any decisions for himself and he has a limited life choice, however, decisions are made on his behalf with care”. Risk assessments are in place to support care plans with guidelines from healthcare professionals, as necessary. From discussion with service users, staff on duty and observation by the inspector, all staff were able to demonstrate a clear knowledge of the service users needs and preferred lifestyle. Service users were observed to be treated with dignity and respect. It was evident that there is a good rapport between the service users and staff team. Staff on duty were observed promoting choice and decisions made by the service users using a variety of communication methods. All service user records were seen to be well maintained, detailed and up to date. DS0000051693.V325367.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 and 17. Quality in this outcome area is good. Service users are assisted to make informed choices regarding all aspects of their daily life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users have a weekly programme of activities. Daily activities undertaken are recorded in service user records. The home has its own vehicle, which is well used for outings. Six service users’ returned their completed questionnaires, with assistance from support staff. Comments made on service user questionnaires included “I sometimes choose to stay in bed longer. Sometimes choose not to go out, choose meals and drinks”, “Sometimes I don’t go out as much as I want because of staff shortages”, “I enjoy watching television and like to go out with someone who supports me. If I show signs of wanting to go out, people who support me, help me”, “ If I ask
DS0000051693.V325367.R01.S.doc Version 5.2 Page 14 for something, this will happen. If I choose not to do something, there is no pressure on me” and “ My room is very tidy and my flat has a cosy, lived in feel”. The inspector spent time with all service users. One service user is unable to communicate verbally, but is able to communicate effectively using facial expressions, gestures and body language. An amount of money is allocated to each service user each year towards a holiday. Holidays are being planned for later on in the year. Service user’s rights and responsibilities are respected and this is evidenced in service user records. The right to be alone is respected by staff, who do not enter bedrooms without permission. Visitors to the home are made welcome. Service user birthdays and other events in the home always include families and friends. Daily routines are relaxed and flexible to meet the service users preferences. From the evidence seen by the inspector and discussion with the manager, the inspector considers that the home would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. All service users said that they enjoyed the food provided and were given a choice. Food stocks were plentiful with fresh fruit, vegetables and salad. The inspector joined three service users for the midday meal. The meal of quiche, sandwhiches and salad, followed by fruit and yoghurt was attractively served and in the quantity requested by the service user. The meal was relaxed with the manager and members of staff chatting to the service users and assisting as necessary. DS0000051693.V325367.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20. Standard 20 was subject to requirement at the last inspection. Quality in this outcome area is good. Service user’s personal and healthcare needs are well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users physical and personal support needs are detailed in care plans. Personal care provided is recorded in daily records. Service user’s records evidenced that regular healthcare checks take place and that healthcare professionals are in regular contact with service users and the staff team. Guidelines are in place to assist staff to meet the healthcare needs of service users. Records were seen to be well maintained and up to date. DS0000051693.V325367.R01.S.doc Version 5.2 Page 16 At the last inspection a requirement was made that the manager must ensure that the medication cabinet is removed from the bathroom as specified by the pharmacist during her previous visits. This has been complied with. Each of the four units has a separate medication cabinet. The manager was advised to ensure that medication keys are kept securely. Medication is administered by staff who have received appropriate medication training. Medication administration records were up to date with no obvious gaps in recordings. DS0000051693.V325367.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. The home has a complaints procedure in an appropriate format for service users. Procedures are in place to protect service users from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure in place and is available in pictorial format for service users. Comments made on service user questionnaires about making a complaint included “ Talking to staff, key worker or the manager”, “ Tell the staff”. Most service users know who to speak to if unhappy, for some service users this may be expressed through changes in their behaviours. The manager and staff team take complaints seriously and this was evidenced in the three complaints recorded in the complaints book. No information concerning complaints about the service has been received by CSCI since the last inspection. The manager confirmed that all staff have received training in the protection of vulnerable adults from abuse this was confirmed by staff on duty but not evidenced in training records. Staff spoken to were clear about the homes whistle blowing policy. Policies and procedures are in place. DS0000051693.V325367.R01.S.doc Version 5.2 Page 18 Policies and procedures are in place, for dealing with service users money and bank accounts. The majority of service users depend on the manager and staff team to manage their personal allowance on their behalf. Very clear, well maintained and up to date records are kept for each service user’s finances. Two staff signatures verify cash spent on behalf of a service user and a receipt obtained. Financial records are audited on an annual basis. DS0000051693.V325367.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is adequate. Service users live in a homely, comfortable and safe environment, which is able to meet the needs of individual service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection some areas of the home have been painted and new carpets fitted. The staff team have worked hard to ensure that the accommodation is comfortable and welcoming. Some areas of the home require urgent repair. One identified communal bathroom needs repair or replacement to the floor covering, wall tiles need replacing and the broken toilet seat replacing. In addition a radiator was found to be leaking badly. An area of ceiling was water damaged and needs to be redecorated.
DS0000051693.V325367.R01.S.doc Version 5.2 Page 20 The manager confirmed that an urgent request for action had been sent to the landlord of the home, but felt that maintenance issues took a long time to be dealt with. The home was found to be clean, fresh smelling and hygienic. There is an infection control policy in the home and staff on duty were aware of this, there are no specific infection issues in the home. It was observed that there was no liquid soap or paper towels available in the communal bathrooms. DS0000051693.V325367.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34,35 and 36. Quality in this outcome area is adequate. Staffing levels are stretched to meet the needs of the service users. The home is dependent on bank staff to cover vacancies. There are robust recruitment procedures in place. Not all staff receive formal supervision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff on duty were clear about their roles and responsibilities. Since the last inspection two support workers and one senior support worker has been recruited. However, the home continues to have five or six full time vacancies for support staff and is without a deputy manager. In addition one member of staff is absent from the home on a temporary basis and a second member of staff has taken paternity leave. These hours are covered by existing staff working additional hours or by regular bank staff. Staff on duty said that the staff team work well together. In discussion with staff and observation it was evident that they are fully aware of the service users wishes and choices. Staff were observed carrying out their duties with
DS0000051693.V325367.R01.S.doc Version 5.2 Page 22 patience and humour. When asked staff were knowledgeable about individual care needs and behavioural guidelines in place. From examination of a sample of staff personnel files, it was evident that recruitment procedures are robust. There is a staff team of thirteen support workers, four support workers have completed NVQ level II and the manager confirmed that several support workers are hoping to commence NVQ training this year. There are individual training records in place for all staff some of these were blank. The inspector was advised that a staff development and training programme was being developed. From examination of a sample of training records, it was not evidenced that mandatory or specialist training is updated on a regular basis. Training records of one senior support worker showed that Fire Safety had not been updated since December 2001, Health & Safety since February 2002 and Moving & Handling since February 2002. The manager confirmed that training records might not be up to date and need updating to include recent training undertaken by staff. Staff on duty confirmed that they felt well supported by the manager, who due to staff vacancies is frequently covering shifts by providing direct care to service users. Not all staff are receiving formal supervision on a regular basis. The manager stated that this is extremely difficult to achieve at present, due to staff shortages. Staff meetings are held on a regular basis and minutes of meetings held were available for examination. Handovers take place and the start of each shift and staff confirmed that communication between the manager and staff team is very good. DS0000051693.V325367.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42. Quality in this outcome area is adequate. The manager needs to be provided with sufficient time and resources to manage the home effectively. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The house has been opened since 1998 but the manager has been in post since 2000. The manager has a NVQ level 4 in Management and is due to complete the Registered Manager’s Award as well as a NVQ level 4 in Health and Social Care. It is very clear that the manager is well respected by members of staff as well as service users. Service users expressed their DS0000051693.V325367.R01.S.doc Version 5.2 Page 24 satisfaction of the care that they receive, the staff team and the management of the home. From examination of duty rosters and discussion with the manager, it is clear that she frequently has insufficient time to carry out some of her administrative and management responsibilities, due to having to cover shifts on the duty roster by providing direct care to service users. On the day of this visit the manager was working from 9am until 3pm and then working until 10pm covering the evening roster. It is not clear whether a deputy manager is to be recruited to assist with specific areas within the home. Service user records were well maintained, although other records needed updating. Policies and procedures are reviewed on a regular basis. There is an annual management review undertaken by the Service Manager. This was not available for examination at this visit. Proprietor representative visits are undertaken on a monthly basis and reports were available in the home. A sample of records relating to health, safety and fire were examined. The manager’s attention was drawn to the fact that the last record of a quarterly service and testing of the fire alarm system having being undertaken was March 2006. DS0000051693.V325367.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 2 x x 2 x DS0000051693.V325367.R01.S.doc Version 5.2 Page 26 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 YA23 Regulation 22 Requirement The manager must ensure that all staff receive training in the protection of vulnerable adults from abuse. That the manager ensures that there is a planned maintenance programme in place and repairs are made to those areas identified in the report. That the manager ensures that there is an adequate supply of liquid soap and paper towels in communal bathrooms. That an action plan is developed for 50 of the support staff, to achieve NVQ level II training. That sufficient staff are employed to meet the needs of the service users. That the manager ensures that there is a staff training and development programme in place. That all staff receive training/ updating in mandatory subjects. The manager must ensure that all staff receive regular, recorded supervision at least six times per year. That the manager has sufficient
DS0000051693.V325367.R01.S.doc Timescale for action 25/03/07 2 YA24 16 25/03/07 3 YA30 13 25/02/07 4 5 6 YA32 YA33 YA35 19 18 19 25/03/07 25/03/07 25/03/07 7 8 YA35 YA36 19 18 25/04/07 25/03/07 9 YA37 24 25/03/07
Page 27 Version 5.2 10 11 YA39 YA42 24 23 time to carry out her management responsibilities That a proprietor representative undertakes an annual development plan for the home. That the manager ensures that all fire safety systems are serviced on a regular basis, as advised by the Fire Authority. 25/04/07 25/03/07 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 DS0000051693.V325367.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000051693.V325367.R01.S.doc Version 5.2 Page 29 - 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!
