Care Home: Blue Roof Bungalow

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What the care home does well The home makes sure that there is enough information about each person using the service so that care workers know how to support them. This includes ensuring that support takes into account the individual`s likes, dislikes and choices. People who use the service are supported to lead ordinary lifestyles in their home and community, maintaining contact with family and friends and engaging in activities that they enjoy. People receive personal care that meets their needs and preferences and the home supports them to access services as appropriate so that they maintain good health. Systems are in place to ensure that people can raise concerns about the service and that they are protected from harm. People who have contact with the home told us that staff are responsive to their requests and concerns. The home provides a spacious, comfortable and clean environment that is appropriate to meet the needs of people who live there. Health and safety checks are carried out in the home to ensure it is a safe place for people to live. Care workers employed to work at the home are recruited safely and given suitable training to ensure they have the knowledge and skills to work effectively with people who use the service. Several positive comments have been made by people who have contact with the home; `Blue Roof Bungalow puts the service user`s needs as first priority...they support residents to achieve and have a rewarding life` (health care professional); `It provides a safe, caring and comfortable environment where residents are treated with respect` (care manager); `The provision is person-centred...there is a calm and happy atmosphere` (relative). What has improved since the last inspection? This was the first inspection of the service. What the care home could do better: A requirement has been made for the provider to review the home`s medication policy to ensure that it gives enough information to the reader about procedures in the home and safe practice. Four recommendations have also been made around developing policies and systems in the home which will help promote good practice. CARE HOME ADULTS 18-65 Blue Roof Bungalow Mill Road Throop Bournemouth BH8 0DW Lead Inspector Heidi Banks Key Unannounced Inspection 30th November 2007 09:00 Blue Roof Bungalow DS0000069866.V353673.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 Blue Roof Bungalow DS0000069866.V353673.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. Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blue Roof Bungalow Address Mill Road Throop Bournemouth BH8 0DW 01202 529508 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) Mrs Katherine Elizabeth Hughes Mrs Katherine Elizabeth Hughes Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Blue Roof Bungalow DS0000069866.V353673.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 only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 3. Date of last inspection Brief Description of the Service: Blue Roof Bungalow was registered as a care home in June 2007 to provide care to three adults with learning disabilities. The home is owned and managed by Mrs Katherine Hughes. Accommodation is provided in single bedrooms with shared bathroom and toilet facilities. The property is accessible to people who use wheelchairs. The bungalow is situated in a semi-rural setting, a short drive from one of Bournemouth’s main shopping centre and local amenities. Parking is available in the driveway at the front of the home. Fees charged by the service are based on individual assessment of needs. At the time of the inspection the range of fees for the home were between £1000 and £1350 per week. Further information on fair terms of contracts and care home fees can be found on the Office of Fair Trading’s website: www.oft.gov.uk. Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection of the service since its registration as Blue Roof Bungalow in June 2007. The inspection was unannounced and took place over 8.5 hours on 30th November 2007. The purpose of this inspection was to assess the home’s progress in meeting the Regulations and key National Minimum Standards. At the time of the inspection there were three people living at Blue Roof Bungalow. During the inspection we were able to take a tour of the home, meet all three people who use the service and observe some interaction between them and staff. Discussion took place with the registered provider, Katherine Hughes, some care workers employed to work at the home and one relative who was visiting their family member. A sample of records was examined including some policies and procedures, medication administration records, health and safety records and service user and staff files. An Annual Quality Assurance Assessment was completed by the provider and submitted to the Commission prior to the inspection. Surveys were distributed by the home to people who use the service, their relatives, care workers, care managers and health care professionals on behalf of the Commission. A total of seventeen surveys were received and information from these sources is reflected throughout the report. A total of twenty-two standards were assessed at this inspection. What the service does well: The home makes sure that there is enough information about each person using the service so that care workers know how to support them. This includes ensuring that support takes into account the individual’s likes, dislikes and choices. People who use the service are supported to lead ordinary lifestyles in their home and community, maintaining contact with family and friends and engaging in activities that they enjoy. People receive personal care that meets their needs and preferences and the home supports them to access services as appropriate so that they maintain good health. Systems are in place to ensure that people can raise concerns about the service and that they are protected from harm. People who have contact with the home told us that staff are responsive to their requests and concerns. Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 6 The home provides a spacious, comfortable and clean environment that is appropriate to meet the needs of people who live there. Health and safety checks are carried out in the home to ensure it is a safe place for people to live. Care workers employed to work at the home are recruited safely and given suitable training to ensure they have the knowledge and skills to work effectively with people who use the service. Several positive comments have been made by people who have contact with the home; ‘Blue Roof Bungalow puts the service user’s needs as first priority…they support residents to achieve and have a rewarding life’ (health care professional); ‘It provides a safe, caring and comfortable environment where residents are treated with respect’ (care manager); ‘The provision is person-centred…there is a calm and happy atmosphere’ (relative). 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. Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: There have been no service users admitted to the home since the registration of the care home as Blue Roof Bungalow. Therefore, these standards could not be assessed at this inspection. Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 9 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s individual needs and choices form the basis of care given at Blue Roof Bungalow, which helps ensure they receive a service that meets their requirements. EVIDENCE: People’s records showed that a considerable amount of information is available to care workers on individuals’ needs, routines, likes and dislikes. The support plans for one person were seen, these indicating that consideration has been given to the way individuals express their individuality and make choices. For example, ‘Assist X to put on her day clothes. X will indicate if she does not like any items by removing them’; ‘X likes quiet time with her (music) tape before getting ready for bed’. Essential information that care workers must know to support people has been put in a separate file so that it is more easily accessible. However, the provider, Mrs Katherine Hughes, agreed that the Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 10 information in people’s main files may benefit from being ‘streamlined’ so that any old information is archived and current information is prioritised. All care workers responding to the survey indicated that they are always given up-todate information about the needs of the people they support and there are enough staff to meet the individual needs of people using the service. Mrs Hughes told us that the home is in the process of developing personcentred plans for each individual who uses the service. Mrs Hughes reported that they are currently liaising with a local advocacy organisation who are assisting in the formation of these plans. Comments received from visitors to the service indicated that the home does well at ensuring individuals’ choices are respected; ‘Although the service user does not speak…residential staff are very sensitive to their needs and nonverbal communication’ (care manager); ‘Service users are encouraged to make their own choices wherever possible’ (care manager); ‘From my contact with the service I consider they very much treat and view each resident as an individual’ (care manager); ‘They give careful consideration to issues of age, disability, gender, faith and sexual orientation’ (care manager); ‘Great consideration is given to individual needs and the group as a whole’ (relative). A sample of risk assessments for one person was seen. These gave information about the activity being risk assessed, the identified risks, the likelihood of harm occurring and actions to be taken by staff to minimise risks. Risk assessments seen included those around the person’s mobility needs including a moving and handling plan, eating and drinking, support with personal care and issues around accessing the community. There was evidence on file of professional input from an Occupational Therapist and Physiotherapist being sought where appropriate to ensure risks are being fully assessed and managed. Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 11 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, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to live an ordinary lifestyle and their engagement in activities and relationships that are important to them is promoted. EVIDENCE: Of the three people using the service, two were attending their respective day services on the day of the inspection while one was spending the day with a relative. The daily diaries and handover checklists for two people indicated that they were engaging in various activities including going for walks in the local area, listening to music, visiting nearby towns, shopping centres and the library, going to the supermarket, doing craft activities, making use of sensory equipment and helping in the home by assisting staff to prepare vegetables and baking a cake. Mrs Hughes told us that they have made links with a local Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 12 advocacy organisation and all service users had recently attended a disco for people with disabilities in the local area. Comments from relatives in surveys indicated that they were happy with the range of activities on offer to their family members. One told us that they felt the home ‘plans for stimulating experiences for clients’ while another stated that their relative gets great pleasure from listening to a variety of music and this is readily provided by staff. Two care managers also commented, ‘They promote activities that X is known to enjoy’; and ‘There are a broad range of activities supported by the home evidencing a broad range of choices made by service users’. People’s rights are promoted by the service in that they have access to all communal areas of the home including their own bedrooms as they wish. Discussion with Mrs Hughes and staff on duty indicated that they are aware of the importance of a person-centred approach to care and are finding effective ways of understanding each individual’s non-verbal communication so that they can promote choice. Observation of care workers interacting with people demonstrated that individuals were treated with respect and their privacy and dignity was upheld. Mrs Hughes told us that all three people who use the service have family who are actively involved in their welfare. Relatives responding to the survey confirmed this, telling us that they felt welcomed into the home and the home was good at helping their family member keep in touch with them; ‘even issues that may not seem urgent but are important to my relative’; ‘They telephone on X’s behalf and pass on messages at any time. There is also a communication book’. Mrs Hughes reported that the home does most of their grocery shopping online with a local supermarket and also has an organic vegetable box delivered each week. Mrs Hughes told us that the home is currently liaising with a dietician regarding portion sizes and nutritional content of food to ensure people who use the service are offered a diet that meets their needs. One relative spoken with during the inspection told us that the home had ensured their family member was given a range of food options to take with them to the day centre which had been particularly important when their appetite was poor. Guidance around eating and drinking from a Speech and Language Therapist was on file for one person, care workers spoken with stating their awareness of the care plan. Observation of the individual eating supper indicated that they were given appropriate levels of supervision during the meal to ensure that they were able to eat safely. Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 13 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s personal care needs are met effectively by the home and their access to health care is actively promoted. EVIDENCE: Feedback from three health care professionals indicated that care workers at the home promoted the privacy and dignity of people who use the service, one adding that ‘privacy, dignity, respect and confidentiality are values that are evident in the way that service users are supported at Blue Roof Bungalow’. One relative spoke highly of the compassion and care shown to their family member and felt that care workers had worked hard to get to know the individual and learn about her personal care needs. Another relative commented that that their family member had benefited from ‘Good personal care, hygiene and cleanliness’. People’s support plans gave substantial detailed information about how they need to be supported in their personal care, including guidance on the Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 14 temperature of water, type of facial wash to use and step-by-step guidance on how to support them in getting into and out of the bath. Written records for one service user showed that health issues had been documented including times when their temperature had been taken, contact with their general medical practitioner, appointments with the dental clinic, incidences of bruising, visits from an Occupational Therapist, episodes of skin inflammation and issues around their mood. A relative told us that their family member’s ‘physical, mental and emotional needs are all met’. Comments from health and social care professionals reflected this; ‘The service users’ health care needs are actively promoted at Blue Roof Bungalow’; ‘Responds well to professional input’; ‘Staff…maintain good liaison with myself, the day service provider and the service user’s family’; ‘They have actively sought contact…to ensure clients have received relevant input…they have purchased equipment which was recommended and sought relevant training for staff to use it.’ One relative told us that their family member had been unwell the previous week which had been responded to effectively by care workers. Care workers spoken with during the inspection confirmed that staffing arrangements were flexible enough to ensure that if a service user was unwell they could remain at the home with appropriate support. The home has a medication policy but it did not provide enough guidance for staff on procedures to follow to protect residents. Following the inspection, we provided some written guidance on this to enable the service to review their policy. People’s medication is stored in individual lockable metal cabinets fixed to the wall of the office area. There are no service users who take responsibility for self-medicating in the home at the present time. Medication is supplied by a local pharmacy who also provide the medication administration record (MAR) charts. A sample of MAR charts was seen. One gap in recording was noted. The reason for this was explained by the manager. However, it is recommended that the home uses identifiable codes to indicate the reasons why administration did not take place at a specific time as listed on the MAR chart. Some people who use the service take homely remedies, a list of which was available on the person’s record. Although the use of each remedy and recommended dosage had been recorded, information about precautions had not been included. The list had been signed by the individual’s general practitioner. Documentation showed that care workers record what homely remedy was given to the service user at what time. It was discussed with the manager that they may want to make the structure for recording the administration of homely remedies more structured so that it provides a clearer record. Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 15 Examination of staff training records indicated that care workers access a training course in medication administration which is externally verified. Discussion took place with the provider around ensuring that staff maintain a level of competence and ensuring that any shadowing or in-house training that takes place in the home is documented. Blue Roof Bungalow DS0000069866.V353673.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is open to feedback from people who use the service to ensure that it is run in their best interests and they are fully protected. EVIDENCE: A copy of the home’s complaints procedure was seen. This includes information on how to make a complaint but timescales by which people can expect a response would benefit from more clarity. The procedure contained information about how to contact the Commission for Social Care Inspection. At the time of the inspection, no complaints had been raised about the service with either the home or the Commission since its registration in June 2007. Discussion with the provider indicated that day-to-day concerns about people’s welfare are recorded in the daily records of individual service users. Evidence of such concerns, and the response of the provider, was seen showing that where people had raised issues these had been fully discussed and recorded with attention to outcomes. The provider agreed that a single system for recording concerns in addition to complaints may be more effective and she will consider implementing this. All care workers responding to the survey indicated that they knew what action to take if a service user, or relative, had concerns about the home. Both relatives responding to the survey told us that they knew how to make a complaint about the care provided by the home if they needed to and that the Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 17 home always responded appropriately to any concerns raised; ‘This service has responded positively to every request.’ This was echoed by a care manager who reported that when concerns had been raised the home had been happy to address these directly. A copy of the multi-agency policy for safeguarding adults is available at the home and the service has a procedure on protecting vulnerable adults which is accessible to staff. The home has told us in their Annual Quality Assurance Assessment (AQAA) that there have been no safeguarding adults referrals made since the service was registered. Inspection of training records for two care workers indicated that they had both received training in abuse awareness. Blue Roof Bungalow DS0000069866.V353673.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home environment is clean, homely and comfortable and meets the needs of people who live there. EVIDENCE: A tour of the premises showed that the home is a spacious bungalow with a large lounge / dining room and a domestic fitted kitchen for communal use. People who use the service have their own bedrooms which showed evidence of careful personalisation to meet individual needs. A relative spoken with expressed their satisfaction with the home environment which they felt suited their family member well. There is a garden to the rear of the property. There is a separate utility room in the bungalow which, at the time of the inspection, was unlocked. This room contains a washing machine, tumble dryer and the boiler which had a hot surface. Discussion with the provider indicated that existing people who use the service do not routinely enter this room. Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 19 However, it was suggested that the room is risk assessed to ensure that risks are minimised. The home is accessible to people who use wheelchairs. The provider told us that they are developing a maintenance plan for the home for the coming year. A tour of the premises showed the home to be in a clean and tidy state. The home has told us in their Annual Quality Assurance Assessment that they have a policy on infection control which was last reviewed in May 2007. The provider indicated her awareness of the most recent guidance from the Department of Health on infection control, ‘Essential Steps’, and confirmed that she would review the home’s procedures in light of this. Inspection of staff training records showed that all care workers access training in infection control and food hygiene during their induction period. Blue Roof Bungalow DS0000069866.V353673.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, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment and training processes are robust which ensures people who use the service benefit from safe, skilled workers who can meet their needs. EVIDENCE: Discussion with the provider indicated that four care workers have achieved a National Vocational Qualification (NVQ) to Level 2 standard, one is doing their NVQ Level 3 and another is scheduled to start their NVQ award in the near future. The records for three care workers were examined for evidence of safe recruitment practices. All three showed evidence of two written references and appropriate checks with the Criminal Records Bureau having been obtained. Two out of the three records showed evidence of proof of identity on file. The provider took immediate action to address the shortfall and therefore a requirement has not been made on this occasion. Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 21 The home sources a six-day induction training programme from the local authority, this covering health and safety, principles of care, infection control, personal care, person-centred planning, food hygiene, emergency aid, communication, personal safety and moving and handling. All care workers responding to the survey told us that their induction had covered what they needed to know to do the job when they started. They also indicated that they were being given training which is relevant to their role and helps them to understand and meet the individual needs of service users. Training records showed that the home has sourced training in challenging behaviour, total communication and diversity from external trainers. Where people require update training in, for example, moving and handling, there was evidence on file that the provider had submitted requests to the local authority. It was suggested to the proprietor that the home continues to promote the uptake of Makaton training in the staff team to ensure that all care workers have the skills to communicate effectively with people who use the service. Both relatives responding to the survey told us that they felt care staff always have the right skills and experience to look after people properly; ‘They have skills and experience combined with friendly care’; ‘Very caring and professional’; ‘There has been continuity of caring, professional and friendly staff’. Health and social care professionals told us that care workers either always or usually had the right skills and experience to support people’s needs, one adding that they felt the manager had been proactive in arranging training for staff where needs had been identified. Blue Roof Bungalow DS0000069866.V353673.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, 40 and 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 run effectively and systems are being put in place to ensure that it promotes the interests and welfare of people who live there. EVIDENCE: The registered provider, Katherine Hughes, is also responsible for managing the home on a day-to-day basis. Mrs Hughes has several years’ experience of working with people with learning disabilities in different settings and reports that she is currently working towards her National Vocational Qualification (NVQ) Level 4 in Care and Registered Managers’ Award. Comments made by care workers in surveys indicated that the management structure works well; ‘Very supportive manager who listens and acts upon any ideas which could Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 23 benefit our clients’; ‘This is a clean, well-run and caring home where staff enjoy their work…the manager is ‘hands-on’ and very involved and dedicated to the staff and service users’. Mrs Hughes told us that they have developed a quality assurance system which has involved distributing questionnaires to people who use the service, their relatives, staff and care professionals to obtain their views about the home. A sample of returned questionnaires was seen, Mrs Hughes informing us that they are awaiting the return of the remaining questionnaires. Discussion with Mrs Hughes indicated that the home planned to put information obtained from the questionnaires into a graph format to share with families of service users at a forthcoming coffee morning. Mrs Hughes was aware that the outcomes of surveys should form the basis of an annual development plan for the service. A sample of the home’s policies and procedures were examined. It was noted that these would benefit from review to ensure that they refer to the home by its current name, that they are all signed and dated and they provide clear and accurate information which complies with the most up-to-date legislation. Prior to the home’s registration as Blue Roof Bungalow in June 2007, a visit from the Dorset Fire and Rescue Service took place at which time a satisfactory standard of fire safety was evident. A fire risk assessment has been undertaken by the provider and a copy of this showed that staff have signed to indicate they had read it. Records showed that weekly checks on smoke alarms and visual checks of fire doors, equipment and escape routes have been undertaken and were up-to-date. Training records showed that care workers have recently undertaken basic fire safety training. The content of this training had been listed on file and included the use of fire extinguishers. Documentation also evidenced that practice evacuations have taken place on a regular basis at various times of day including one at 9.45pm when two service users were in bed. Documentation showed that a weekly health and safety audit is in place to monitor the recording of fridge and freezer temperatures and ensure that the home is in a suitable state of repair. Blue Roof Bungalow DS0000069866.V353673.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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 2 X 3 X Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 YA20 Regulation 13(2) Requirement The provider must review the home’s medication policy so that it contains enough information on the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home to ensure people who use the service are fully protected by procedures. Timescale for action 30/04/08 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 provider should ensure that where medication is not administered as prescribed this is reflected on the medication administration record (MAR) chart by the use of identifiable codes. Homely remedies lists should contain information about the precautions for each remedy. The home should review their infection control policy to reflect the most recent guidance from the Department of Health. DS0000069866.V353673.R01.S.doc Version 5.2 Page 26 2. YA30 Blue Roof Bungalow 3. 4. YA39 YA40 The home should produce an annual development plan based on the feedback obtained through their quality assurance process. All policies and procedures in the home should be reviewed to ensure they contain accurate, up-to-date information and are signed and dated. Blue Roof Bungalow DS0000069866.V353673.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Blue Roof Bungalow DS0000069866.V353673.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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