Care Home: 3 Beech Close

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What the care home does well What has improved since the last inspection? The managers and staff team have worked hard to meet all the requirements from the previous inspection, so there have been improvements in almost all areas since the last inspection. What the care home could do better: There are only two requirements following this inspection. The organisation must ensure that people know what they pay for their care as well as what they pay for their rent. The Housing Association must clean or replace the stained flooring in the bath/shower rooms. CARE HOME ADULTS 18-65 3 Beech Close 3 Beech Close Dunstable Beds LU6 3SD Lead Inspector Nicky Hone Unannounced Inspection 20th August 2008 10:45 3 Beech Close DS0000071726.V370705.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 3 Beech Close DS0000071726.V370705.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. 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3 Beech Close Address 3 Beech Close Dunstable Beds LU6 3SD 01582 757655 01582 757656 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) TACT UK Ltd Ms Lucy Gyau-Ampofo Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: Learning Disability - Code LD The maximum number of service users who can be accommodated is: 8 This is the first inspection of 3 Beech Close since it transferred to TACT UK Ltd. The last key inspection was on 26/06/07. 2. Date of last inspection Brief Description of the Service: 3 Beech Close is a home for up to eight adults with learning disabilities. On 01/03/08 TACT UK Ltd took over as provider of the service from the Bedfordshire and Luton Mental Health and Social Care Partnership Trust (BLPT). The bungalow is owned by the MacIntyre Housing Association (MHA), which is responsible for the maintenance and upkeep of the building. The bungalow is situated approximately one mile from Dunstable Town Centre. It shares a site with three other registered care homes and a resource centre. The bungalow has eight single bedrooms which each have a washbasin, two lounges, a dining room, kitchen, laundry and bathing facilities. Four of the bedrooms are large enough for people who also have physical disabilities, and there are overhead hoists in one of the bathrooms and in one of the shower rooms. There is a physiotherapy room and a small sensory room (snoozelen). There is a fair-sized, enclosed garden to the rear of the property, with adequate parking to the front of the building. The home provides its own transport. Full information regarding the fees, including any additional charges, was not known at the time of writing. From the documents we looked at, it would seem that the people who live here know what rent they pay to the Housing Association, but do not know the full cost of their care. 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. TACT UK Ltd. took over as provider of the service at 3 Beech Close from the Bedfordshire and Luton Partnership Trust (BLPT) on 1st March 2008. The building is owned and maintained by MacIntyre Housing Association. At the time of this inspection there were two people living at 3 Beech Close. Following our inspection in June 2007, we (the Commission for Social Care Inspection) rated 3 Beech Close as an adequate service. We carried out a random inspection on 22/02/08, when we looked at standards with a safeguarding theme. We sent a letter to the provider following the inspection, telling them about the issues we raised with the manager. We did not write a full report, or make any requirements, because the service was about to transfer to the new provider. For this inspection (20/08/08) we looked at all the information that we have received, or asked for, since the last key inspection of 3 Beech Close. This included: • The AQAA (Annual Quality Assurance Assessment) that the manager completed and sent to us in May 2008. The AQAA is a self-assessment that focuses on how well outcomes are being met for people living at the home. It gives the manager the opportunity to say what the home is doing to meet the standards and regulations, and how the home can improve to make life even better for the people who live there. The AQAA also gives us some numerical information about the service; Surveys which we sent to the home to give to people who live at 3 Beech Close, to their relatives/carers, and to staff. We received 3 replies: 2 from residents; 1 from relatives; and 0 from staff. What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement; Any safeguarding issues that have arisen; and Information we asked the home to send us following our visit. • • • • 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 6 This inspection of 3 Beech Close included an unannounced visit to the home on 20/08/08. We met both of the people who live at the home, and observed the way staff were supporting them. Both people have profound learning and physical disabilities and do not use words to communicate, so they were unable to tell us about their home. We also looked at some of the paperwork the home has to keep. This included care plans, risk assessments, medication charts, and records such as staff personnel files, staff rotas, menus and fire alarm test records. What the service does well: The home is managed well, so the people who live at 3 Beech Close have a good quality of life, based as far as is possible on their wishes. Staff we saw and spoke with show a great deal of respect for the people who live at 3 Beech Close, and relationships between the staff and the people they support are clearly very good. As far as is possible to tell, the two people who live here are happy with their lives and the way they are supported. One of the staff said “ The care is good, we work well as a team and we do everything we can for the people we support”. The staff had recently organised a barbeque and received a thank you card from one person’s relatives. In it the relatives had written “Thank you for the lovely lunch and barbeque – we much appreciate all the extras and hard work this entailed.” No complaints have been received. There is information available about the service the home offers, written in different ways, and produced on tape for people to listen to, and full assessments of people’s needs have been carried out. Support plans and risk assessments give good information to staff on the way each person prefers and needs to be supported, people’s healthcare needs are met and medication is handled safely. Each person has an activity plan and records show that people lead full and busy lives, both in the home, in their local community, and further afield. Staff strive to find different activities and things for people to do, and people have a holiday if they want one. People’s nutritional needs are met and food provided is healthy and well balanced. The people who live at 3 Beech Close, their relatives and/or representatives know how to complain if they need to, and staff have been trained to keep people safe from harm. The bungalow is light and airy, brightly decorated in strong, warm colours, and comfortably furnished. Lots of additional touches such as flowers and pictures 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 7 make it feel very homely. People’s bedrooms are very individual to them and a range of equipment is provided to meet each person’s needs. The snoozelen can be a really fun room, or a nice quiet relaxing one, depending on the person’s mood and what they want at the time. The gardens are attractive and well maintained. Staff are recruited well, offered a range of training to make sure they can do their jobs properly, and all have either got, or are working towards, a professional qualification in care. Staff receive regular supervision and team meetings are held monthly. There are a number of ways the home checks out that the service it provides is of a high quality. We had no issues about health and safety. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 8 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 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 9 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): 1, 2, 5 People who use this service experience adequate quality outcomes in this area. There is good information available about the home, and the people who live here know their assessed needs will be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: 3 Beech Close has a statement of purpose and an updated service user guide, which uses pictures so that people who live at the home are more able to understand what it is about. Both give good information about the service provided. The deputy manager told us that both the statement of purpose and the service user guide have been put onto tape for anyone thinking of moving into the home who might prefer that format. There was a copy of each of these documents in one of the files in the person’s room, as well as a simple complaints procedure, and a copy of the last CSCI report. We looked at the records the home keeps about one of the people who live here. There was a detailed, up to date, assessment on file of the person’s 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 10 needs and the ways in which the person needs to be supported. This assessment was done in mid-2007 when it was planned the home should transfer to a new provider. We did not see a contract, or statement of terms and conditions of residence on the file we looked at. We did not see any thing that would give the person clear information about the total amount they have to pay for the care they receive, and how this is covered by benefits. 3 Beech Close DS0000071726.V370705.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): 6, 7, 8, 9, 10 People who use this service experience good quality outcomes in this area. Care plans and risk assessments contain good information and detailed guidance for staff so that they can meet the needs of the people who live at 3 Beech Close. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Each person has several files, containing different documents, and all are kept on a shelf in the person’s bedroom. We looked at the records the home keeps for one of the people who live here. This person has profound disabilities and complex needs, so requires assistance with every aspect of daily life. A detailed support plan gave good, clear guidelines for staff on all care needed. The plan was written in words, and had also been translated into symbols and pictures. The plan had been signed by an advocate as having been read to the 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 12 person. There was a ‘communication passport’ on the file, detailing ways to communicate with this person, and evidence that staff had made a referral to the speech and language therapist to get additional ideas for communication. Risk assessments had been undertaken and were on file, including the use of a lap belt for this person when they are in their wheelchair, the use of bed rails, the risk of pressure sores, and so on. All the risk assessments were personal to this person, not generic assessments which had been in place at our previous inspection. A moving and handling care plan giving full guidance and detailed instructions to staff on the way the person prefers to be moved had been updated on 03/08/08. Care reviews take place annually, involving the person’s care manager (social worker), relatives (if possible) or an advocate, and home staff including the person’s keyworker. A number of actions had been proposed at this person’s review: the keyworker said the majority had been addressed. 3 Beech Close DS0000071726.V370705.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): 11, 12, 13, 14, 15, 16, 17 People who use this service experience good quality outcomes in this area. People are offered a range of educational and leisure opportunities so that they can lead full, satisfying and interesting lives. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Detailed notes are written every day by staff and these gave us a good picture about the life of the person whose records we looked at. The notes showed that the person has a very active life, going out most days to do things such as shopping, walking in different parks, going to the cinema, going to the snoozelen at Beech Close resource centre, attending a music session at college and so on. Staff also recorded in-house activities such as watching DVDs, listening to music, story reading, and aromatherapy sessions. Each activity is given a score based on the person’s reaction, so everyone knows which 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 14 activities the person has enjoyed. Staff said they hold a meeting each week with the two people to discuss activities and plan for the week ahead. Staff work hard to find new things for people to do, and new places for them to go. Both people who live at 3 Beech Close have a travel card and they use the Dial-a-ride minibus sometimes when they go out. We were told that on Wednesdays (the day of our inspection) they usually go to the market to buy the fruit and vegetables for the coming week, but this Wednesday one person had a doctor’s appointment so the plans had changed and they went into town instead. The two people do not do everything together, but often go out separately to different activities. We were pleased to learn that one person’s relatives have agreed the person can go on a short holiday to see if they enjoy being away from their home, so staff were planning this with the person. The other person has a holiday every year. One of the staff went through the person’s “My File” with us. This staff member is the person’s keyworker and was very proud of the file that had been created. Numerous photographs had been taken of the person when they were doing all sorts of activities. The file shows ‘what I do at home’ and ‘my bedroom’, as well as activities outside the home such as a fun day at a local park, a disco with a good friend, enjoying a music session at college, visits to a farm and the zoo, holidays in Minehead and Hertfordshire, a Christmas Extravaganza, trips to the theatre, circus and pantomime, and so on. The staff had also collected and put in the file other items, such as the ticket and brochure from the theatre, as reminders of what the person had done. One person has their food via a PEG tube (see Personal and Healthcare section of this report), so meals provided are for one person only. Staff support this person to choose which meals they want on their menu for the week, and a good record is kept of the food which has been provided. The menu showed that the person is supported to choose a healthy, balanced diet. 3 Beech Close DS0000071726.V370705.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): 18, 19, 20 People who use this service experience good quality outcomes in this area. People’s healthcare needs are met and medication is handled safely so that people are supported to be as healthy as possible. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The support plans we saw gave staff very detailed guidance on the way the person needs and likes to be supported with their personal care. These details had been worked out by staff who have known the person for many years and have learnt the ways in which the person communicates their needs and preferences. These plans, like the activity plans and medication plan had also been produced using symbols and pictures. One of the files we looked at contained a comprehensive Health Action Plan (HAP). This was started in May 2007, and had been reviewed and updated in July 2008. It contained information to show that all the person’s healthcare needs are met. Staff take the document with them when they accompany the 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 16 person to each appointment, and the professional makes an entry. We saw entries from the dietician, physiotherapist, hearing service, optician, dentist, wheelchair service and so on. The staff team have asked the speech and language therapist to assist them to find additional ways of communicating with this person. This person has their food through a tube into their stomach (PEG feed). The staff have all been trained by the hospital nurse and dietician to make sure they can administer this safely and in the best way for the person, and also by the manufacturer so that they are competent in the use of the specific equipment used. This person receives their medication through the PEG. Also on the file we saw a booklet entitled “all about me” which has been prepared by staff to accompany the person if they have to go to hospital. It is kept updated so that it is ready if there is an emergency. Charts which record when staff assist this person to turn over in bed had been completed well, and the person is weighed regularly so that their weight can be monitored. We looked at the medication file. The medication policy had been reviewed in July 2008. The policy states that all staff must attend an accredited medication training course, and must then have practical training in the home and be observed by the manager or deputy at least six times before they are deemed to be competent and are allowed to administer medication. Staff files showed that all staff who administer medication had been through this process, and had also had training from Boots the chemist on 13/08/08. There were guidelines on the file for the administration of ‘when required’ medication specific to the person supported. These had been reviewed and signed by the doctor. We saw that the Medication Administration Record (MAR) charts had been signed correctly. Medication for each person is kept in a locked cupboard in their bedroom. We saw records to show that staff monitor the temperature of the cupboard: this had been done at 2a.m. each night, and showed that even at that time the temperature (although not exceeding the recommended 250C) was quite warm. We recommended that the temperature is checked at other times of the day as well. 3 Beech Close DS0000071726.V370705.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): 22, 23 People who use this service experience good quality outcomes in this area. People who live here, and their relatives, have been given information about how to complain, and they can be confident that staff have been trained to make sure they are safeguarded from harm. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: In the AQAA the manager told us that no complaints have been received in the past 12 months. We saw that each person has a copy of the complaints procedure on one of the files in their bedroom, which is in straightforward, simple language and uses pictures and symbols. Staff files showed that staff have received training in safeguarding adults. Staff we spoke with had a good understanding of what safeguarding means, and what abuse is, as well as how to report anything that might occur. 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 18 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): 24, 25, 27, 28, 30 People who use this service experience excellent quality outcomes in this area. 3 Beech Close is very well decorated, furnished, maintained and cleaned so that people have a very comfortable, homely, hygienic and pleasant place to live. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The bungalow is very attractively decorated in bright, warm colours and looks fresh and clean throughout. It is comfortably furnished, and made very homely with bright pictures, flower arrangements and other homely touches. There was a large bowl of fruit on the table in the dining room, and in one of the lounges, numerous photographs of the people who live at the home on outings and participating in activities, and pictures of their relatives. 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 19 A covered patio outside one lounge has a table and chairs and the gardens surrounding the bungalow are attractively landscaped, well maintained, and easily accessible to the people who live here. One end of the bungalow was specifically designed for people who also have physical disabilities, and use a wheelchair. There is overhead tracking in the bathroom and the shower room, and equipment such as a shower table so that people’s individual needs can be met. The flooring in the shower room was stained: the deputy manager said the Housing Association would be replacing this. Each of the people who live at 3 Beech Close have chosen the colours for their bedrooms, and items to go in their rooms, making the rooms very personal to them. The snoozelen has a range of sensory equipment, such as coloured lights, mobiles, a disco ball, pictures, music and things which give different touch sensations, and is used frequently by the two people who live here. Colourful mobiles have also been hung in the bathrooms and these move as the warmth in the room increases. 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 20 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): People who use this service experience good quality outcomes in this area. Staff are well recruited, and receive training and supervision so that they can do their jobs well. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The deputy manager said there are two staff on duty at all times, including two staff awake during the night. During the day the manager and/or the deputy manager are also on duty. There are occasions when two staff are needed to assist one person with personal care, so the second person is unsupervised. However, staff are good at making sure the person is safe, and making sure they check on him/her frequently. We looked at the personnel files of four members of staff. We were satisfied that the home had obtained all the information needed before staff start work at the home, such as a Criminal Record Bureau (CRB) check and two written references. 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 21 In the AQAA the manager said that 6 of the 9 staff have been awarded a National Vocational Qualification (NVQ) in care, and the other 3 are undertaking the course. Staff told us that they have been trained within the last twelve months in all the ‘mandatory’ topics except infection control, so had attended courses on moving and handling, food hygiene, first aid, fire safety, health and safety and safeguarding. They had also had training in PEG feeding, epilepsy (including administration of special medication), and diabetes. Staff files we looked at had evidence in the form of certificates to show that all these courses had been undertaken. There was also evidence that all staff undergo a thorough induction when they start work at the home. Staff said they get regular supervision from the manager or deputy manager, and staff meetings are held monthly. 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 22 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): 37, 39, 41, 42 People who use this service experience good quality outcomes in this area. 3 Beech Close is managed well so that the people who live here have a good quality of life and are kept safe. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager was not on duty on the day we inspected, and was not able to come to the home. However, the deputy manager ably assisted us with the inspection. The manager and deputy manager have been at the home for a number of years, and they and the staff team have worked hard since out last inspection 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 23 to improve the service offered to the people who live here. It is an indication of the quality of leadership that there are only two requirements resulting from this inspection, both of which are out of the manager’s hands. One of the staff told us that they get good support from the manager. There is a system in place to monitor the quality of the service provided. As the people who live at 3 Beech Close are unable to communicate verbally, the manager wrote to families, advocates and professionals who visit the home such as the sensory officer, to ask their views on the service provided. A summary of the findings was written and the results were very positive. Weekly and monthly in-house audits of different areas of the service are undertaken, and the provider’s representative visits monthly (as required by regulation 26) and leaves a report of the visit in the home. The operations manager from TACT is working closely with the Housing Association to make sure the property is kept well maintained. We looked at the log book in which staff record when they have done tests of the fire alarm and emergency lighting systems. Tests had all been carried out as required. Fire drills are held monthly, the last one having been done on 17/08/08. 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 24 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 4 2 3 3 X 4 X 5 2 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 4 25 4 26 4 27 2 28 4 29 4 30 4 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 X 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 Requirement Information regarding the fees charged to service users, what they cover, and the cost of all facilities and services not covered by fees, must be made clear for each service user. This information must be recorded in the service user contract, and be agreed with each service user (if appropriate) and/or a suitable independent representative for each service user. This requirement is carried forward. 2 YA24 23(2)(d) All parts of the home must be well maintained so that people have a pleasant place to live. The stained flooring in the bath/shower rooms must be cleaned or replaced. 31/12/08 Timescale for action 31/10/08 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 26 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 YA20 Good Practice Recommendations The temperature of the medicine cabinets should be monitored at a range of times across the day/night to make sure the temperature remains below the recommended maximum for drug storage. The number of staff on duty should be monitored to make sure there are always enough staff to meet people’s needs and keep them safe. 2 YA33 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 3 Beech Close DS0000071726.V370705.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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