Care Home: Baylis Place

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What the care home does well The expert by experience said `The home was very large and welcoming. The staff were very friendly and it was clear they have a good relationship with the resident, as I observed staff sitting, chatting and playing a game with the resident. When looking around the bedrooms I liked the fact they were all very spacious and had their own en suites, I also like the fact they have a lockable storage cupboard next to the bedroom. I liked the fact residents are able to choose how to have their rooms decorated. I think it is a good idea booking a holiday in Scotland as the resident may not have been there before. He also said `I liked the fact that residents have a lot of people they can talk to if they have a problem or did not feel safe. I also like the way the complaints, health and safety and other policies are displayed in easy read format with pictures. There was also a fire procedure in picture format so residents know what to do if there is a fire.` The staff are continuing to develop the persons care plan and are spending time developing a relationship with the person and getting to know them so that they are fully aware of their needs and wishes, and how these can best be met. There are adequate staffing levels that allow people to spend time with the individual, getting to know them and meeting their needs. The admissions policy and practice to date reflects a process that allows the person to move into the home in the way that suits their needs the best. What has improved since the last inspection? This section is not applicable as this is the first inspection of the home. What the care home could do better: CARE HOME ADULTS 18-65 Baylis Place Wawne Road Hull East Yorkshire HU7 4YG Lead Inspector Sarah Rodmell Key Unannounced Inspection 15th January 2008 09:30 Baylis Place DS0000070696.V357870.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 Baylis Place DS0000070696.V357870.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. Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Baylis Place Address Wawne Road Hull East Yorkshire HU7 4YG 01482 877011 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) cyd.akrill@swantoncare.com Swanton Care and Community Ltd Mrs Cyd Akrill Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 10 Not Applicable 2. Date of last inspection Brief Description of the Service: Baylis Place is owned by Swanton Care and Community Ltd and is registered to provide care and accommodation for up to 10 people who have a learning disability. The home is situated in the Bransholme area of Hull, with a mixture of residential, care settings, a GP practice and shops nearby. Accommodation is provided over two floors, with the first floor being accessed by either the stairs or a passenger lift. There is a third floor that is purely for staff; it includes a staff room and changing and showering areas. Communal accommodation is provided on each floor, and includes lounges and dining/kitchen areas. There are 5 single bedrooms on each floor (all en- suite) which offer good sized accommodation and personal storage areas. There is a car park to the front of the property and a sensory garden to the rear, with a lawned area to the side. The registered manager confirmed in the AQAA (Annual Quality Assurance Assessment) form that the weekly fees start at £1437 per week and that people pay additionally for other services including chiropody and hairdressing. Baylis Place DS0000070696.V357870.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. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the registration of the home, including information gathered during a visit to the home. Since registration the CSCI has not received any new information about the home from the registered provider and there have been no letters or complaints to us from other people. As part of the inspection we send out an Annual Quality Assurance Assessment (AQAA), which is a self-assessment document that the registered person must complete and return to the Commission. It should show how well the home is meeting regulations and National Minimum Standards, what has been done to improve the service since the last inspection or since registration and what still needs to be done. The provider returned the AQAA to us so we had the necessary information to help us check what relatives of people living in the home and professionals working with them think of the service. As the service is new there is currently only one person living in the home and they have only lived there for a short time. We sent out surveys to professionals working with the individual and their representatives. The one survey returned to us was not completed as the person felt that due to the short period of time the person had lived in the home they were unable to answer the questions in the survey. The site visit took place on 15 January 2008, beginning at 9.30 am and ending at 4.30 pm. The provider was not told in advance of the date or time we planned to visit. The manager was available for all of this visit and we spoke to the manager and staff during the visit. We looked around the home including people’s rooms and the shared areas of the home, and we inspected records of people’s care, staff files, health and safety documents and other records. An expert by experience Mr Lee Fiskel joined us at the visit and he separately completed a tour of the premises and talked to staff. An ‘expert by experience’ is a person who, because of their shared experience of using services and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. They produced a report and this information has been used to help us to make the judgements in the report. Due to the service user only living in the home for a short period of time there has not been the opportunity for the development of practice and written evidence to support assessment and judgement for all of the standards. This is addressed further in the main text of the report and these will be assessed at the next visit. Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The expert by experience commented that : • I think there should be a sofa bed available to allow for friends and relatives to stay over, as some friends and family may have a long journey to visit the home and also residents should have the choice to have friends stay over as I do at home. I also think that the residents should have picture menus to be able to point out what they would like to eat. DS0000070696.V357870.R01.S.doc Version 5.2 Page 7 • Baylis Place • • I would recommend there is a staff rota available for residents to have easy access to, and there should be photographs and names of staff so visitors and residents know who people are and who is on duty. Once there are more residents I think they should hold resident meetings to decide what activities they would like to do. Also there should be an activities choice board for residents to choose from. Some of the documents in the home are continuing to be developed, particularly into user friendly versions. Once these are in place it would increase opportunities for people who may live in the home to access these documents. 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. Baylis Place DS0000070696.V357870.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 Baylis Place DS0000070696.V357870.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, 3, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wanting to use the service undergo a full needs assessment, which tells staff about them and the support they need. People are provided with information about the home and the services provided, which helps them to make positive choices about moving into the home. EVIDENCE: There is an up to date statement of purpose and service users guide, which provide information to prospective service users and their relatives regarding the home. These documents are new and are to be further developed into user friendly documents, including pictorial formats, but are not yet available in these versions. The registered manager recorded in the AQAA and told us at the time of the visit that the service user guide will be written specifically for each individual as they enter the home. The one person living in the home has a file that includes details of their individual assessment undertaken by both the manager and the staff. This was undertaken prior to the person moving into the home. The notes included details about the staff visiting this person in their old home to spend time getting to know them prior to the move. Staff spoken to confirmed this. Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 10 There is an admissions policy held within the home and the registered manager told us that they would not admit people in an emergency unless a full assessment had been completed by the home. In the AQAA the registered manager had put ‘ We strive to make the experience as least traumatic as possible for anyone coming into the home and go at a speed dictated by that person’. The statement of purpose also included details of the admission process and how this process will be completed at a pace suitable to the individual. The registered manager told us that the home do not yet have a written contract with the person living there and that this is being developed. Baylis Place DS0000070696.V357870.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by good systems of care planning; they are involved in decisions in their lives and are protected from risks. EVIDENCE: The person living in the home has only lived there for a couple of months. However, there is a comprehensive care plan in place, that clearly states the needs of this person and how the home are to meet these. This care plan has already been reviewed. The registered manager told us that they are planning to review the format of the care plan and are already developing this further. The staff in the home are continuing to develop the care plan based on their knowledge of the individual. They told us that they include this person in many decisions, including what to wear, what time to get up, what to eat and where to go. Staff also said that, when they go shopping they ask this person if they Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 12 like things before they buy them. On the day of the site visit the person did not get up until late morning and their care notes indicate that staff are keeping detailed records of whether this person enjoys different activities that they participate in. The registered manager wrote in the AQAA that ‘ X is able to make simple choices and is encouraged to do this. We have had to listen to family/friends/ other professionals to build as full a picture as possible’. Consultation is already taking place in the home and the individual is involved in decisions about their daily life. However, due to the short period of time they have lived in the home it is not possible to fully assess this and this will be addressed at the next inspection of the home. The individuals care file included different risk assessments relating to their daily life. These help people to be protected from the risk of harm. There is a policy on confidentiality and when spoken to staff reflected a good understanding of confidentiality and how to handle people’s private information. Baylis Place DS0000070696.V357870.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the opportunity to take part in varied activities and are supported to keep in contact with family and friends. People receive a nutritious diet, with choices that helps to meet their needs. EVIDENCE: The AQAA recorded that the registered manager has already developed a link with CASE, which is an adult education facility run locally. She said that people living in the home would be able to access this facility and would have links with local job centres and colleges. Other information recorded in the AQAA was that information is held in the home relating to community activities, that there is an open door policy and that a coffee morning has been held. The home held a Christmas party and fundraising event for charity. There is a minibus available for people to use to access the community. Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 14 Individual activity records are kept, with a risk assessment in place for each activity undertaken to help to make sure that the activity is as risk free as possible. There is a planned weekly programme of activities and each trip out is recorded with details of how this trip went and whether the person enjoyed it. It also describes the place they visited and how accessible it was. The expert by experience said, ‘I found out the resident takes part in activities during the day and on evenings and weekends depending on how she is feeling. The activities that the resident has been involved with are; - trips out to the seaside, the park, and to ‘The Deep’ aquarium - shopping - painting activities - gardening - DVD’s - music - shopping - sensory room - games room - going to church - TV - foot massages - Mexican evening - Christmas party The staff also told me they are planning a long weekend away possibly in Scotland in a caravan.’ The registered manager wrote in the AQAA that there is a generic timetable of activities available to be developed individually for each person living in the home. They also said that the home is seeking to recruit a life skills coordinator to arrange activities. Staff told us that they are offering different activities to the person in the home which include going to church and baking, and that although they seemed to enjoy church they did not enjoy the baking. On the day of our visit the person in the home received a visit from a relative and staff told us that this happens regularly, and that friends are able to visit whenever they want. However, due to the short period of time the person has lived in the home, it is not possible to fully assess this and this will be addressed at the next inspection of the home. The expert by experience told us ‘The only resident living at the home at the moment goes food shopping with staff, and staff informed me that she sometimes will point out food she would like.’ Breakfast was observed to be a relaxing and quiet time for the person living in the home with two members of staff assisting her with this. There are menus in place that offer a variety of foods and the staff told us that the person living in the home is involved in the food shopping. The menus offer a variety of foods across a week. However, Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 15 they only offer two choices each mealtime and these do not always include a healthy option. The expert by experience told us ‘ The menu was typed up in small writing. I think there should be pictures so it is more accessible for residents to look at. There were only two choices at meal times, one meat and one vegetarian. There was some fruit and vegetable options available for healthy eating, but I think there should be more healthy options. I also think there should be more choices available at meal times. Two choices is not enough for people to choose from.’ Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are met within the home. EVIDENCE: The registered manager wrote in the AQAA that although it is difficult for the person living in the home to express a lot of choices, the staff have worked with others who know her well before appointing a key worker. Staff told us that they help to maintain the person’s privacy and dignity by making sure that doors are closed when personal care needs are being undertaken, and that they talk to the person and tell her what they are going to do. The persons care file included any health needs that they may have an details of specialists involved in the meeting of their needs. The registered manager wrote in the AQAA that specialist equipment and training is provided and specialist help, advice and assistance is sought on a regular basis in order to help in the meeting of peoples’ needs. Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 17 The AQAA recorded that the staff have improved their skills in the administration of medication, as initially people were nervous in completing this. To support them, the registered manager developed an assessment covering all of their concerns and has arranged for staff to spend time with the registered manager and deputy manager until they feel comfortable completing medication administration. This is in addition to the formal training that staff receive. Medication is stored safely and up to date records are kept of all medicines entering, administered in and leaving the home. There are clear records of all staff signatures which would help with any audit trail and the registered manager told us that staff have undertaken Medication training, certificates for this were held in staff files. Peoples’ needs regarding terminal illness and dying have not been able to be fully addressed due to the short period of time they have lived in the home. Consequently, it is not possible to fully assess this and this will be addressed at the next inspection of the home. Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. People would be supported to raise concerns and are protected from harm. EVIDENCE: The registered manager wrote in the AQAA that there is a complaints policy held in the home, which is available in an easy read format. The expert by experience told us ‘There was a copy of the complaints policy on the notice board which was in easy read text with pictures.’ The registered manager confirmed to us on the day of the visit that there have been no complaints made since the home opened. She also recorded that they have contacts with advocacy groups who have visited the home. The expert by experience told us, ‘The staff told me that if a resident had a problem they could talk to their key worker, family liaison officer, manager or staff. If they did not feel safe they could talk to their key worker, manager or operations and development officer. ‘ The registered manager recorded in the AQAA that there is a Safeguarding policy held within the home. When we spoke to staff they gave us positive responses about their understanding of protecting vulnerable people and what they would do if a situation of possible harm occurred. Baylis Place DS0000070696.V357870.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): 24, 25, 26, 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, comfortable and modern home. EVIDENCE: The home is newly built and offers comfortable, very clean and modern accommodation for people. The expert by experience said “I found the home was welcoming and very clean and tidy. The building was very new and was decorated and furnished to look modern. I thought it looked like a show room.’ The registered manager confirmed in the AQAA that ‘ the home is decorated and equipped to a very high standard’. Individual bedrooms are of a good size with an en-suite shower room. Systems have been put in place to assist people with mobility needs for example, over head tracking systems are in place, should they need to be installed in an individuals room. The expert by experience said ‘I noticed the doors were very wide and there was a lift to the first and second floor so it was wheelchair Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 20 accessible’. Furniture is provided and, in addition, there is a large lockable storage cupboard for each person in the hallway next to his or her room. In addition to peoples’ own rooms there are lounges where people could relax or socialise. There is also a sensory room and the expert by experience said ‘ We then looked in the sensory room which was very colourful and all lit up. I liked the sensory room as it gives residents a quiet, calm and relaxing environment.’ Additionally there is a room for people to spend time with their visitors in private. The expert by experience said ‘ There was also a quiet room and a visitors room which I thought was good because this gives residents and friends and family space to have some quiet time.’ There is a separate room for storing and charging equipment such as wheelchairs. The expert by experience said ‘ I also liked the fact there was a room for charging wheelchairs and equipment. This is a good idea as wheelchairs will not need to be stored in residents bedrooms.’ Baylis Place DS0000070696.V357870.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): 31, 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. People are supported by adequate numbers of staff who are correctly recruited and who receive training. EVIDENCE: The registered manager wrote in the AQAA that there is a ‘good staff team, experienced and trained to a good standard, all mandatory training is ongoing’. The information in the AQAA recorded that there are 6 full time and 4 part time care staff, with 4 none care staff. The duty rota seen on the day of the site visit showed that there are 2 staff on duty 24 hours a day. The statement of purpose recorded that there will be a staffing ratio of 2 staff to each service user. The registered manager confirmed in the AQAA that all people who work in the home have had satisfactory employment checks. People’s individual files included an application form, two written references and the reference numbers of their Criminal Records Bureau (CRB) check. When we talked to Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 22 staff they all confirmed that they had undertaken these checks prior to being able to work in the home. However, with the reference numbers only available, we were not able to review the CRB checks and it is recommended that these are made available. People’s files also included copies of their contracts of employment and job descriptions, that people have been provided with to be able to understand their role. The registered manager when asked showed us a copy of the General social Care councils Code of Conduct (GSCC) which details the standards that care staff should be working to, The registered manager told us in the AQAA that staff undertake the Learning Disability Award Framework (LDAF) training. She told us at the visit that staff have commenced this recently as it could only be started once there was someone living in the home. Also that staff undertake a mandatory induction, which is accredited by Skills For Care, this helps to make sure that staff training is meeting National Standards. The registered manager included in the AQAA information that currently 45 of the staff team hold an National Vocational Qualification (NVQ) level 2 or equivalent in care and that 22 of the staff team are working towards achieving this. We were also told that 50 of the staff team have received training in food handling. People’s files included copies of certificates for different courses that they have attended this included Moving and Handling, Hoist, Fire, Protection of Vulnerable Adults, Medication and First Aid training. The registered manager has commenced some staff supervision and when asked staff felt that they were supported and if they had a problem they could approach the manager. However, due to the short period of time they have been employed in the home it is not possible to fully assess this and this will be addressed at the next inspection of the home. Baylis Place DS0000070696.V357870.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): 37, 38, 39, 40, 41,42 & 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a well managed home, where systems are in place to help them to be involved in its development. EVIDENCE: The registered manager has recently been registered with the CSCI. The statement of purpose detailed the qualifications and experience of the registered manager including that she is a qualified nurse and has had management experience in care settings for a number of years. The registered manager wrote in the AQAA that there is an ‘ open door culture. An open and inclusive approach’. The registered manager also included in the Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 24 AQAA that there are internal evaluations, and that feedback and comments are sought. On the day of the visit we were told that although there are staff meetings and audits being undertaken, a formal system of quality assurance is still being developed. There are policies and procedures available within the home and the registered manager confirmed in the AQAA that these had been reviewed over the last year. These policies included Confidentiality, Fire Safety Physical Intervention and Smoking. The registered manager told us that people are supported to manage their personal monies and that their representatives manage any benefits or bank accounts. Records were seen of the individual’s monies, which were up to date and correct, with receipts for purchases being retained. The registered manager included in the AQAA that the following equipment has been serviced or tested as recommended; electrical circuits, the lift, the hoist, fire detection and fighting equipment and the gas appliances. As the home has only been open for a short period of time it has not been possible to fully address the overall management of the home. Consequently, it is not possible to fully assess this standard and this will be addressed at the next inspection of the home. Baylis Place DS0000070696.V357870.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 2 2 3 3 3 4 3 5 1 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 1 35 3 36 N/A CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 N/A 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 N/A 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 N/A 3 3 2 3 3 3 N/A Baylis Place DS0000070696.V357870.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 YA5 Regulation 5 Requirement The registered person must make sure that each person living in the home has a contract/statement of terms and conditions. Timescale for action 28/02/08 Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 27 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 3 Refer to Standard YA14 YA17 YA25 Good Practice Recommendations The registered person should address the recommendation for an activities board to be displayed. The registered person should review the menus to make sure that there are healthy options available. The registered person should make sure that there are facilities for friends and relatives to stay overnight if the person wishes them to. The registered person should make sure that 50 of the staff team are qualified to National Vocational Qualification (NVQ) level 2 or equivalent in care. The registered person should make sure that staff rotas and menus are in pictorial/easy read formats. The registered person should make sure that CRB checks are available to the CSCI upon request. The registered person should make sure that the Quality Assurance system is fully used within the home. 4 YA32 5 6 7 YA33 YA34 YA39 Baylis Place DS0000070696.V357870.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Baylis Place DS0000070696.V357870.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. 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