Care Home: 61 Adkin Way

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What the care home does well A pre-admission assessment makes sure that the home only admits residents whose needs can be met and identifies whether equality and diversity needs can be met. Prospective residents can try out the home before deciding to live there. Residents know that their assessed and changing needs are met in the way they prefer. Residents are supported to make choices and are involved in daily routines. They are supported to take acceptable risks within a risk assessment framework. Residents benefit from a stimulating lifestyle and have good access to the local community. Residents are supported to have quality relationships with their families and they are encouraged to eat healthily. Residents receive personal care in the way they prefer. Improved staffing levels, staff morale and confidence has led to better consistency of care for residents. Staff support residents to access healthcare and to take their medication safely.Residents and their relatives know their concerns will be dealt with. Staff are trained to know how to protect residents from potential abuse. The home is kept clean and free from infection. Residents` benefit from enough trained staff to meet their needs. Recruitment checks carried out to make sure staff are suitable to work with residents. The home is well managed and the manager continues to improve systems in the home. Relatives say: `Communicating with relatives, trying to support my resident to have the life they really want and incorporate new activities.` `They try to listen to individuals and fulfil individual and particular needs to the best of their ability.` `At the moment there is a very friendly, companiable feel to the house with banter and laughter when we visit, from what we observe the four residents seem happy.` What has improved since the last inspection? Redecoration and garden developments have improved the residents` environment since the last inspection. Staff recruitment and team morale has improved and staff and relatives have seen how residents have benefited from this. There is good evidence of staff responding positively to changes and that care practice has improved. The views of residents and others are sought to help develop the service. Health and safety systems are kept up to date. Relatives say: `The house manager and key worker deserve a great deal of credit for raising the morale of staff and showing more imagination when setting up activities. Standards are more professional this year`. `We have every confidence in the manager. We think the continuity of staff is so good, they are able to really get to know the residents and vice versa. In the years that our resident has lived at Adkin way, this last 12/18 months has been the calmest and happiest.` What the care home could do better: Refurbishment of bath and shower rooms is needed to meet mobility needs and uphold residents` dignity. Relatives say: `Greater attention to menu planning and diet. Back up important routines when the key worker is absent.` `By ensuring an appropriate stimulating and varied programme is in place with clear outlining and use of the daily wall chart. More visible picture signs for guidance and communication throughout the home.` CARE HOME ADULTS 18-65 61 Adkin Way Wantage Oxfordshire OX12 9HN Lead Inspector Jill Chapman Unannounced Inspection 27 September 2007 10:30 th 61 Adkin Way DS0000013060.V346626.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 61 Adkin Way DS0000013060.V346626.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. 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 61 Adkin Way Address Wantage Oxfordshire OX12 9HN 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) 01235 762279 adkin.way@unitedresponse.org.uk None United Response Emma Williamson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2007 Brief Description of the Service: 61 Adkin Way is registered to provide 24-hour residential care and support for up to four people with a learning disability. It is a detached house with a garden and is similar in style to the neighbouring properties. It is domestic rather than institutional in character. At the time of this inspection the home was providing long-term accommodation and support for four people, with Autism, who have lived there since it was first registered. The home is managed by United Response, an organisation with experience of working with people with a learning disability, although the premises are owned by a housing association. Service users are registered with a local GP practice and have access to specialist services as required. At the time of inspection, the fees for this service were £2043.30 per week. 61 Adkin Way DS0000013060.V346626.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 the 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 10:30 am and was in the service for five hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or 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 services and other people seen during the inspection or who 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 standard of the service. The inspector spoke to the Manager, Area manager and two staff on duty. A tour of the building and garden was carried out. The four residents were at home during the inspection and some of the daily routine was seen. Records relating to care, staffing and health and safety were sampled. Pre inspection surveys were received from four residents, three relatives/advocates and one health professional. What the service does well: A pre-admission assessment makes sure that the home only admits residents whose needs can be met and identifies whether equality and diversity needs can be met. Prospective residents can try out the home before deciding to live there. Residents know that their assessed and changing needs are met in the way they prefer. Residents are supported to make choices and are involved in daily routines. They are supported to take acceptable risks within a risk assessment framework. Residents benefit from a stimulating lifestyle and have good access to the local community. Residents are supported to have quality relationships with their families and they are encouraged to eat healthily. Residents receive personal care in the way they prefer. Improved staffing levels, staff morale and confidence has led to better consistency of care for residents. Staff support residents to access healthcare and to take their medication safely. 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 Page 6 Residents and their relatives know their concerns will be dealt with. Staff are trained to know how to protect residents from potential abuse. The home is kept clean and free from infection. Residents’ benefit from enough trained staff to meet their needs. Recruitment checks carried out to make sure staff are suitable to work with residents. The home is well managed and the manager continues to improve systems in the home. Relatives say: ‘Communicating with relatives, trying to support my resident to have the life they really want and incorporate new activities.’ ‘They try to listen to individuals and fulfil individual and particular needs to the best of their ability.’ ‘At the moment there is a very friendly, companiable feel to the house with banter and laughter when we visit, from what we observe the four residents seem happy.’ What has improved since the last inspection? Redecoration and garden developments have improved the residents’ environment since the last inspection. Staff recruitment and team morale has improved and staff and relatives have seen how residents have benefited from this. There is good evidence of staff responding positively to changes and that care practice has improved. The views of residents and others are sought to help develop the service. Health and safety systems are kept up to date. Relatives say: ‘The house manager and key worker deserve a great deal of credit for raising the morale of staff and showing more imagination when setting up activities. Standards are more professional this year’. ‘We have every confidence in the manager. We think the continuity of staff is so good, they are able to really get to know the residents and vice versa. In the years that our resident has lived at Adkin way, this last 12/18 months has been the calmest and happiest.’ 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 Page 7 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. 61 Adkin Way DS0000013060.V346626.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 61 Adkin Way DS0000013060.V346626.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, 4 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A pre-admission assessment makes sure that the home only admits residents whose needs can be met and identifies whether equality and diversity needs can be met. Prospective residents can try out the home before deciding to live there. EVIDENCE: The home has an up to date Statement of Purpose and Service User Guide to give prospective residents and their representatives’ information to help decide if the home is suitable. The Service Users Guide is produced in two versions; one has pictures and symbols to assist those with communication difficulties. No new residents have been admitted by the home, but there is an assessment process in place to make sure any future residents needs can be met by the home. The pre-admission assessment includes looking at whether equality and diversity needs can be met. Introductory visits would be carried out and a trial period arranged for the resident to see if the home suits their needs. Residents’ files were sampled and show that they were given a Contract of Terms and Conditions and a Care Charter to show what services they can expect from the home and what their responsibilities are. 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know that their assessed and changing needs are met in the way they prefer. Residents are supported to make choices and are involved in daily routines. They are supported to take acceptable risks within a risk assessment framework. EVIDENCE: A previous requirement to complete the transfer of care plans into a more suitable and consistent format has been met. Care plans were sampled and show that all residents now have detailed care plans with descriptive guidelines on how they want to be supported and how to make sure they are safe. There are good guidelines for each part of the day to show residents preferred routines. The manager said that care plans are completed with the resident and their family and are constantly reviewed and updated. It was seen that individual daily diaries have been developed and they show that care plans are being met. A relative said ‘In the past year strenuous efforts have been made to meet my residents needs.’ 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 Page 11 There is good written information to show that residents make choices, including their characteristics and their preferred characteristics in staff. Their likes and dislikes are clearly documented. Staff have been trained in MAKATON to improve communication with residents and help them make choices. Residents are now involved in the day to day running of the home. A resident surveyed said ‘if I don’t want to do something I don’t have to do it. It is up to me’ There is a risk management plan and risk assessments sampled cover a variety of potential individual risks. These were well documented and gave clear guidelines to help staff reduce the risks. It is recommended that bathing risk assessments give more detail about the risks considered, including falling, scalding and drowning. 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a stimulating lifestyle and have good access to the local community. Residents are supported to have quality relationships with their families and they are encouraged to eat healthily. EVIDENCE: The home has further developed activity programmes for residents. The pre inspection information shows that activities are evidenced in Individual Guidelines and Personal Care Plans. Residents all have detailed guidelines in their personal care plans that show how they want to be supported with different activities. An Activities Log gives good detail of what activity has taken place, if the resident liked it and how they coped with it. Team meeting minutes show plans for new ideas and activities. A relative said ‘this year has been innovative in the approach to setting up activities and improving lifestyle.’ The use of activity boards and pictures help residents plan their day. One resident has completed a computer course, which they enjoyed. Residents have developed their skills in looking after themselves and their home. 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 Page 13 Staff helped residents tell of trips to local pubs, cafes, shops, parties, social clubs and getting out daily. The use of the local swimming pool and gym is being increased. The manager said that residents have at least two holidays a year. This was discussed with residents who with staff support told of holidays with parents and with staff. One resident prefers day trips and these are arranged to their choice. There was good evidence that residents are supported to keep in touch with their relatives and some have regular stays with their parents. One resident has an advocate. There are healthy eating folders are in place, health action plans and mealtimes are flexible. Weight charts are kept as part of healthy eating monitoring. The inspector joined residents for a lunchtime snack and they joined staff making their sandwiches and chose their fillings. There was a supportive and friendly atmosphere during the meal. 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal care in the way they prefer. Improved staffing levels, staff morale and confidence has led to better consistency of care for residents. Staff support residents to access healthcare and to take their medication safely. EVIDENCE: Residents all have detailed guidelines in their personal care plans. These are well presented and include pictures and show residents preferences in routines and personal care. There has been input from a Speech and Language specialist to improve understanding between the staff and residents. Communication profiles show how staff can communicate with each individual. The manager confirmed that residents are involved in the preparation of these to fully reflect their wishes. Daily diaries evidence that their care plans are carried out. Feedback from relatives and staff is that improved staffing levels, staff morale and confidence has led to improved consistency of care for residents. Residents’ health care needs are well documented. There is a medical profile for each resident, health action plans and risk assessments. There is evidence 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 Page 15 of liaison with health professionals and records of consultations and appointments. Regular dental checks and eye tests are documented. There is an appropriate medication system for the handling and safekeeping of residents’ medication. A nomad system reduces the opportunity for errors and staff carry out checks to the system weekly. A stock control system is in place to help audit the system. Staff receive a medication induction and it is recommended that this be documented to evidence the training given 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives know their concerns will be dealt with. Staff are trained to know how to protect residents from potential abuse. EVIDENCE: The Commission has not received any information about any complaints made about the home. There is a user-friendly complaints procedure in place. A previous requirement to keep a complaints record has been met; there is now a Complaints Log. The home is aware of information about a concern from a neighbour that has been received by the Local Authority. It is recommended a record of this is made in the complaints log and updated if any further action or information is received. One relative surveyed seemed unclear about whether there is a formal complaints procedure but all said that they knew who to talk to if they had a concern. One said concerns have been followed up and acted upon. The Commission has not received any information about any safeguarding Adults issues relating to this home. Staff are trained in the Protection Of Vulnerable Adults in the first three months of employment and have refresher training every year. The manager is aware of local Safeguarding Adults procedures and it is recommended that she take POVA level 2 training for managers if this is available from the Local Authority. Recruitment checks are carried out to make sure that staff are suitable to work with residents. There are financial procedures to make sure no financial abuse takes place. The system for the safekeeping and managing residents personal monies was seen 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 Page 17 and found to be accurate. An inventory is kept of individual residents belongings to make sure these are kept safe. 61 Adkin Way DS0000013060.V346626.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. 27, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Redecoration and garden developments have improved the residents’ environment since the last inspection. Refurbishment of bath and shower rooms is needed to meet mobility needs and uphold residents’ dignity. The home is kept clean and free from infection. EVIDENCE: Staff have worked hard to improve the environment for residents. The communal areas downstairs have been redecorated and broken furniture repaired or replaced. One resident showed their bedroom, which was redecorated by a parent and confirmed that they chose the colours, curtains and bedding. Another bedroom is in the process of being redecorated. A charity grant obtained to develop a sensory garden, a pond area has been rebuilt and a Summerhouse has been erected to make into a sensory room. The staff office has been exchanged with the original sleep in room to give residents better access to the computer. 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 Page 19 A previous requirement to complete outstanding refurbishment has not been fully met. The providers’ previous plans to refurbish a bathroom to make it ensuite and to create another en-suite from excess landing space have not been carried out and these need to be pursued with the landlords. It was seen that all bathrooms in the home are in need of refurbishment. The dated style and condition of bathroom suites, being flowery and feminine, do not uphold the dignity of the male residents who live there. A walk in shower room that has tiles that need replacing has been patchily repaired over the years. A recommendation from an Occupational Therapist that one resident requires assisted bathing facilities has not been carried out and must be without further delay. The current corner bath is not suitable for adaptation; therefore refurbishment of this bathroom should take priority. Refurbishment of the bathrooms should take into account that three of the current residents are middle aged and may need assistance in future years. The home was found to be clean and hygienic. Monthly hazard checks are carried out to identify any repairs needed. There is a cleaning rota and staff are trained in infection control. 61 Adkin Way DS0000013060.V346626.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): 32, 33, 34 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from enough trained staff to meet their needs. Staff recruitment and team morale has improved and staff and relatives have seen how residents have benefited from this. Recruitment checks carried out to make sure staff are suitable to work with residents. EVIDENCE: A previous requirement to reduce the use of agency staff has been met. The team is now almost fully staffed. One regular agency staff is employed, attends training with team and is on short-term contract. A relatives survey said ‘We think the continuity of staff is so good, they are really able to get to know the residents and vice versa’ Staff deployment is three staff on daytime shifts except when some residents go home to their families at weekends this is reduced to two. At night there is a sleep in staff and a waking night staff. Common induction standards and a training schedule are underway. Specific training is planned to meet residents’ individual needs, for example 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 Page 21 Challenging Behaviour level 4 and MAKATON. The manager and staff were very positive about the accessibility of the organisations staff training schedule. The training co-ordinator keeps data about staff training and sends reminders to the home when it is due to be updated. Staff spoken with and records sampled confirmed that relevant training is provided. Recruitment procedures carry out checks on the suitability of staff to work with residents. Staff spoken with confirmed the induction process and core training that is provided. A previous requirement, that comprehensive evidence must be kept in the home to evidence the vetting process for new staff has been met. Staff files were sampled and show that these are carried out. Supervision has been developed to be monthly and key worker meetings are held to set goals. Monthly team meetings are held and team-building days are planned. Staff said that morale has improved and that they work well as a team. They said that they and the residents have benefited from an increase in permanent staff. A programme of National Vocational Qualification training is underway and soon the target of 50 staff with NVQ Level 2 or above will be reached. 61 Adkin Way DS0000013060.V346626.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, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and the manager continues to improve systems in the home. There is good evidence that staff responding positively to changes and that care practice has improved. The views of residents and others are sought to help develop the service. Health and safety systems are kept up to date. EVIDENCE: The manager has completed the National Vocational Qualification Level 4 and Registered Managers Award. There was good feedback from relatives about the competence of the manager and how care practice has improved. There is good communication between the manager and staff, good staff morale and improved working relationships. The manager said that staff are taking more 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 Page 23 responsibility for good practice. Staff see the manager as, ‘hands on’, supportive and accessible. There is increased participation with local providers and social services, with staff from the home attending provider forums and ‘looking at us’ review. There is a Quality Assurance system and surveys have recently been carried out to get the views of residents, relatives and advocates. Surveys for residents are presented in a pictorial format. A new service plan is in place that includes goals for the residents. The Area manager carries out quarterly monitoring visits and monthly regulation 26 visits. A previous requirement about Regulation 26 reports is not fully met. In sampling regulation 26 reports, it was seen that there still needs to be more written evidence that the required areas are covered. This was discussed with the Area Manager who came to the home on the day of the inspection. Health and safety audits are carried out monthly to identify and maintenance or safety issues. The manager monitors that health and safety checks are completed. Health and Safety and Infection Control are mandatory training for staff. Health and safety records were sampled and found to be up to date. Previous requirements to develop a fire safety risk assessment and about keeping a copy of residents accident forms on their file, have been met. 61 Adkin Way DS0000013060.V346626.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 3 2 3 3 X 4 3 5 3 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 3 25 X 26 X 27 2 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 4 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 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 3 3 X X 3 X 61 Adkin Way DS0000013060.V346626.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 YA39 Regulation 26(4) Requirement Regulation 26 visits and the resulting reports must address all required areas. This is outstanding from 04/02/07 The registered persons must provide the Commission with a written timescale for the refurbishment of the bath and shower rooms. The registered persons must ensure that a recommendation from an Occupational Therapist that a resident requires assisted bathing facilities be carried out Timescale for action 29/11/07 2 YA27 23(j) 29/12/07 3 YA29 23(n) 29/12/07 61 Adkin Way DS0000013060.V346626.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 2 Refer to Standard YA9 YA20 Good Practice Recommendations That bathing risk assessments give more detail about the risks considered, including falling, scalding and drowning. The medication induction should be documented to evidence the training given. The manager should undertake POVA level 2 training for managers if this is available from the Local Authority 3 YA23 61 Adkin Way DS0000013060.V346626.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way 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 61 Adkin Way DS0000013060.V346626.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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