Care Home: Bredon Respite Care Service

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What the care home does well The people who use Bredon and their representatives, including relatives and health and social care professionals, value the service and say they are satisfied with the standard of care and support provided. Bredon is a new respite care service in Halton. It was commissioned by the local authority to replace services that had recently closed. People have told us that the change to the new service has been well managed so they are confident that the new service will meet their needs. People have had their needs assessed and have been involved in developing their own plans so they receive care and support in the way they prefer. One of the relatives told us that the transition to Bredon for their son was very successful and another said "Tea visits were very helpful in putting our daughter`s mind at rest about coming to a new location with new staff". The staff are well trained and skilled and work together as an effective team so they can meet the needs of the people who come to stay at the home. They have developed good working relationships with the people who use the service, their families and health and social care professionals. Staff were said to be courteous polite and skilled and one relative stated; " The staff are excellent, we have no worries at all". What has improved since the last inspection? This was the first inspection of a newly registered service. Creative Support is an established not for profit organisation that is committed to continually developing and improving the services it provides. What the care home could do better: Managers must make sure that the home`s policies and procedures on staff recruitment are followed so vulnerable people are safeguarded from abuse. Care management assessments should be requested from the local authority so managers and staff know that a comprehensive assessment has been made of each individual`s needs. Action must be taken to make sure that all people receive the support to make important decisions. This may involve making assessment of their capacity to make decisions and consulting their representatives and advocates where necessary to make sure that any decisions made are in the person`s best interests. It is recommended that mirrors should be provided in bedrooms and bathrooms so people who stay at the home can check their clothing themselves so their independence and dignity is promoted. A shower curtain should be provided so staff can promote privacy and dignity when assisting people in the shower. Checks should be made to make sure that the smoke seals are fitted correctly so people will be safe in the event of a fire. CARE HOME ADULTS 18-65 Bredon Respite Care Service Lapwing Grove Palacefields Runcorn WA7 2PJ Lead Inspector David Jones Unannounced Inspection 21 and 25 April 2008 09:30 Bredon Respite Care Service DS0000070381.V361774.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 Bredon Respite Care Service DS0000070381.V361774.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. Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bredon Respite Care Service Address Lapwing Grove Palacefields Runcorn WA7 2PJ 0161 236 0829 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) bredon@creativesupport.org.uk Creative Support Ltd Mrs Jacqueline Anne Unsworth Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to people of the following gender:- Either. Whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Physical disability - Code PD The maximum number of people who can be accommodated is: 4 Date of last inspection: This is the first inspection of this service. Brief Description of the Service: Bredon Respite Care Service is a new care home providing short-term accommodation and respite care for up to four people with a learning disability, and or a physical disability. It is operated by Creative Support, a not for profit organisation that provides a range of personal care services for people with a learning disability in the North West of England. The accommodation available includes a lounge/dining room with kitchen, four single bedrooms with en-suite bathroom facilities, a separate communal toilet, a fully equipped laundry and access to enclosed gardens. In addition there is an office and staff sleeping in room with en-suite toilet. The care home is on the ground floor of a building owned by the local authority, which also accommodates other services for people with a learning disability. It is within walking distance of local shops, public transport and other amenities. Information about Bredon Halton Respite Service, including copies of the most recent inspection report, is made available to each resident and their representatives and can be obtained by contacting Creative Support on 0161 236 0829. Fees payable for this home are based on an individual financial assessment conducted by the Social Services Department. There are no additional charges other than sundry items charged at cost. Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 2 stars. This means that the people who use the service experience good quality outcomes. This key inspection was unannounced. The visit to the home took place on two days and took five hours and 25 minutes in total. It started at 02:30 pm on the first day. This visit was just one part of the inspection. Before the visit, the manager was asked to complete a questionnaire to provide detailed information about the agency and how it is meeting the needs of the people who its service. CSCI questionnaires were made available for the people who use the service, their families and health and social care professionals, such as nurses and social workers, and their views about the agency have been taken into account. Records for three of the people who use the service were checked to see the care they receive; one person was spoken with and their views taken into account. Staff recruitment and training records were examined. Some of the home’s policies and procedures were also checked. What the service does well: The people who use Bredon and their representatives, including relatives and health and social care professionals, value the service and say they are satisfied with the standard of care and support provided. Bredon is a new respite care service in Halton. It was commissioned by the local authority to replace services that had recently closed. People have told us that the change to the new service has been well managed so they are confident that the new service will meet their needs. People have had their needs assessed and have been involved in developing their own plans so they receive care and support in the way they prefer. One of the relatives told us that the transition to Bredon for their son was very successful and another said “Tea visits were very helpful in putting our daughter’s mind at rest about coming to a new location with new staff”. The staff are well trained and skilled and work together as an effective team so they can meet the needs of the people who come to stay at the home. They have developed good working relationships with the people who use the service, their families and health and social care professionals. Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 6 Staff were said to be courteous polite and skilled and one relative stated; “ The staff are excellent, we have no worries at all”. 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. Bredon Respite Care Service DS0000070381.V361774.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 Bredon Respite Care Service DS0000070381.V361774.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): 1, 2, 3, and 4 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. There is a good system to introduce people to this service and people who use it have their needs assessed so they know that the service is suitable to meet their needs. EVIDENCE: Bredon is a new respite care service in Halton. It was commissioned by the local authority to replace services that had closed. The people who use the service and their families told us that the change over to this new service has been well managed. The service is valued and all say it meets the needs of the people who use it. Records show that all people who have used the service to date have had their needs assessed. The assessments have been completed by the manager or other qualified and experienced staff and have included identification of health and social care needs, likes, dislikes, aspirations and personal preferences so people receive care and support in the way they prefer. However, none of the case files checked during the inspection visit contained a copy of the local authority’s individual care management assessment. This needs to be obtained before an individual uses the service so managers and staff can be confident that each person’s needs have been comprehensively assessed. Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 9 All people responding to the CSCI survey told us that they received enough information to help them with their decision-making. The service provides a statement of purpose and service users guide, which is illustrated with photographs and drawings to help people understand the information. The unit business manager for Bredon said that the illustrations in the service users guide had helped some people but others would still have difficulty understanding the information. Consideration could be given to producing the service users guide in a range of formats so all people who use the service are helped to understand it. Some agencies working with people with learning disabilities have used audiovisual technologies including CDs and DVDs to help them provide information which people understand and relate to. Tea visits were offered to all people looking to use the service so they had opportunity to familiarise themselves with the home and make an informed choice about staying there. One of the relatives told us that the transition to Bredon for their son was very successful and another said, “Tea visits were very helpful in putting our daughter’s mind at rest about coming to a new location with new staff”. Bredon Respite Care Service DS0000070381.V361774.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 and 9 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service are involved with the development of their individual care and support plans so they receive the care and support they need in the way they prefer. EVIDENCE: Case records checked during the inspection visit, including feedback for the people who use the service and their relatives, show that the home is establishing clear and effective care planning arrangements. All people responding to the home’s survey questionnaire described the standard of care as good or excellent. They said staff understand the person’s needs and they are very satisfied with the support received. The people who use the service are involved in the planning of care that effects their lives. Staff encourage them to make a positive contribution to their care by helping them to complete an additional assessment known as the “Listen to Me” assessment. This is illustrated with drawings and is designed to help them Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 11 express their needs, personal preferences, likes, dislikes and life goals in their own words so they receive care and support in the way they prefer. Three case records were read as part of the inspection. Each contained an assessment, risk assessment and care plan. The care plans seen were at different stages of development but all provided sufficient information about the individual’s needs and how they would be met. Risk assessments are in place so possible hazards are identified and where necessary safeguards are put in place so people are safe. From reading case records, observation and discussion with staff it is clear that a key principal of the service is that people are valued and helped to maintain independence and control of their lives. For example, one person’s assessment confirms that they are able to take control of their own medicines with limited support from staff. One of the risk assessments seen included a limitation being placed on the person’s freedom of movement and power to make decisions. Discussion with the unit business manager confirmed that this had been done in the best interests of the individual but it was not clear from the records whether they or their representatives had been consulted appropriately. The unit business manager advised that there were doubts about the individual’s capacity to understand the complexity of such issues but there had been no assessment of their capacity to determine what assistance they would need to make these decisions. Where there is any doubt about a person’s ability to make informed decisions, an assessment of their capacity to make the decision should be made. If necessary their representatives and advocates should be consulted to determine what assistance the individual needs to make the decision. This will help to make sure that the rights of the people who use the service are protected so they always receive the assistance they need when making decisions. Bredon Respite Care Service DS0000070381.V361774.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, 15, 16, and 17 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the services have opportunities to take part in a range of activities and are encouraged to practice ordinary domestic routines so they can live the life they choose and develop independent living skills. EVIDENCE: Managers and staff understand the importance of helping people to achieve their goals, follow their interests and be integrated into community life in a way the individual wants. They recognise that people who use the service have diverse and differing needs and make sure that arrangements made to support them reflect this. All people responding to the home’s survey questionnaire described the activities on offer and standard of food as excellent or good. Records, including the activities file and personal care files, show that people who use the service are encouraged to follow their own interests and have opportunities Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 13 to develop ordinary domestic living skills such as food preparation, cleaning and shopping. There was only one person staying at the home at the time of the visit. They were doing some artwork. They told us they liked doing pictures, singing on the karaoke machine and going out to the pub with staff. They said the food was nice and they showed us that they choose what they want to eat from the fridge and freezer. Records show that staff support people to purchase and prepare nutritious, varied, balanced meals so healthy eating and personal choice is promoted. Relatives responding to the survey told us that they are made welcome. The manager intends to build on good relationships that have been established with the people who use the service and their families by arranging a family support group. One relative told us: “The home provides a welcoming setting which allows my daughter to relate well to the staff. This is more important than a physical quality of the building, which happens to be excellent. It encourages her to want to go back”. Bredon Respite Care Service DS0000070381.V361774.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 and 20. People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs so they receive personal care in the way they prefer. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Person centred planning is put into practice so people receive the level of support they need. Staff were observed to respond to an individual’s needs in a sensitive and considerate manner. They listened to them and spoke to them as an adult would speak to another adult so their dignity and respect was promoted. Staff were skilled at offering well timed but discreet prompts so the individual was helped to achieve what they had set out to do and their independence was promoted with minimum support. Personal health care needs, including specialist needs and dietary requirements, are recorded in each person’s care records so staff know what to do when a person is unwell including who to contact when further advice and guidance or is required. A visiting district nurse told us that she has good working relationships with the staff. Other health and social care professionals Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 15 who responded to the CSCI surveys told us that the staff have the skills they need; they seek and act on advice so the health care needs of the people who use the service are met. Staff have received training on administration, safekeeping and recording of medication and have access to a clear medication policy. A check of medication records showed that the people who use the service received appropriate levels of support with their medication so their health care needs are met and their independence is promoted. Bredon Respite Care Service DS0000070381.V361774.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 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home has robust complaints and adult safeguarding procedures so the people who use the service are able to express their concerns, are listened to and are safeguarded from abuse and neglect. EVIDENCE: There have been no complaints about the home since it opened. People who use the service are able to express their concerns and have access to an effective complaints procedure so they are listened to and their concerns are acted upon. Creative Support provides an illustrated complaints procedure and another version is available on a DVD so all people can access the information. All people responding to the survey tell us they know how to make a complaint. All staff receive training on safeguarding vulnerable people and have access to appropriate robust procedures for responding to suspicion or evidence of abuse so people are safe and protected from abuse. Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 17 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. People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home provides suitably adapted, clean, well furnished and well equipped accommodation so the people who use the service live in comfortable, homely and safe surroundings. EVIDENCE: The home is within a large building that also accommodates other services for people with a learning disability, including day care. It does not look like other domestic houses so it does not blend in with the local community. However, it is spacious, well equipped and furnished and decorated in a way that the people who use it like so it provides a homely place to stay. People who use the service and their representatives say the accommodation is excellent. It is bright, cheerful, airy and clean and has good lighting and heating systems so people are comfortable and warm. Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 18 Mirrors are needed in bathrooms and bedrooms so people can dress themselves and check their own clothing. This will help to promote their independence. A shower curtain is needed in one of the bathrooms so staff can promote privacy whilst providing assistance to people using the shower. There is a maintenance programme and routine safety checks are made to ensure that fire precautions are effective. However it was noted that there were large gaps between the smoke seals and the doorframes so the smoke seals might not work in the event of a fire. The business manager reported this to local authority so action is to be taken to make sure the building is safe. Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 19 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, 35 and 36. People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. The people who use the service were supported by a well trained and effective staff team but staff recruitment procedures were not always followed so vulnerable people were not fully protected. EVIDENCE: The people who use the service and their relatives express confidence in the staff team’s abilities. All relatives responding to the CSCI survey and the home’s quality assurance questionnaire made positive comments about the staff. Staff were said to be courteous, polite and skilled and one relative stated; “The staff are excellent, we have no worries at all”. Health and social care professionals told us that staff are skilled and always seek and act on advice when required. One social care professional said, “Individuals health care needs are always met during their short stay at the home.” Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 20 Staff told us that Creative Support provides excellent training opportunities including a nine day “Skills for Care” induction training programme, health and safety training including manual handling and people handling, infection control, protection of vulnerable adults, person centred planning and equality and diversity. Two recently recruited staff members told us that the inductiontraining programme was thorough and gave them with skills and confidence they need to carry out their work effectively. One staff member told us that they had benefited from training on equality and diversity and said this had helped them with person centred planning and understanding how differing needs should be respected and met. This shows us that the staff in the home are trained and have the skills they need to support the people who use the service. Information provided before the inspection indicates that two of the home’s seven support workers have an NVQ in care at level 2 or above. The unit business manager told us arrangements are being made to provide opportunities for all staff to get NVQ level 2 or above. Creative Support has thorough staff recruitment procedures that are designed to make sure that vulnerable people are protected from abuse. However, it was noted that one staff member had started work before a reference had been received from their previous employer. The person’s recruitment records indicated that a suitable reference had been received but further examination of the reference found that it related to another person. This means that vulnerable people were not fully protected. Staff told us that they feel valued and well supported in their work. Staff meetings take place regularly. Supervision sessions are regular and staff find them helpful. Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 21 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 and 42. People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The service is well managed so that it is run in the best interests of the people who use it for respite care. EVIDENCE: The manager is experienced in the care and support of people with a learning disability and has previously managed a respite care home. They are appropriately qualified with a range of qualifications including NVQ in care to level 4 and have recently completed the registered manager’s award. Managers and staff understand the importance of equality and recognising and valuing diversity. They have received training on equality and diversity and person centred planning and can show how they have put their training into practice so people receive care that meets their differing and individual needs. Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 22 Creative Support approaches quality assurance in a number of ways. It is accredited as an Investor in People organisation. The Investors in People award is a nationally recognised quality assurance framework for training and development of staff. In addition there is an established quality assurance framework within the organisation. This includes a range of quality audits and checks. The views of the people who use the service are gathered by questionnaires after every visit. This information is used to measure the quality of services provided and staff are able to show where improvements in service delivery have been made. For example, managers have responded to issues raised by improving television channels by providing a digital receiver and a new CD player. It is envisaged that an annual quality assurances report will be published and made available to the people who use the service and their representatives. Creative Support seeks to ensure the health and safety of all employees and residents. Risk assessment and risk management is central to the conduct of the home. The unit business manager and the registered manager ensure that risk assessments are carried out for all safe working practice topics and significant findings are recorded and reviewed, so people are safe. All service installations are new. Information provided indicates that fire precautions are in place and routine maintenance checks of electrical appliances, heating system, water temperatures and fire alarms, will be undertaken as required. Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 23 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 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 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 3 X 3 X 3 X X 3 X Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? First 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 YA34 Regulation 19 (1) Requirement A member of staff must not be employed to work with people who use the home until all required recruitments checks and references are in place so people are safe from possible harm, poor practice or abuse. Timescale for action 31/05/08 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 YA2 Good Practice Recommendations Care management assessments undertaken by the local authority should be available in the home so managers and staff know that a comprehensive assessment has been made of each individuals needs. People who use the service should receive all the support they need when making important decisions. This may involve making assessment of their capacity to make decisions and consulting their representatives and advocates where necessary. 2 YA7 Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 25 3 YA24 Mirrors should be provided in bedrooms and bathrooms so people can check their clothing themselves and their independence and dignity is promoted. A shower curtain should be provided so that staff can protect people privacy and dignity when helping them to shower. Smoke seals should be fitted correctly on fire doors so people will be safe in the event of a fire. Arrangements should be made to ensure at least 50 of staff acquire an NVQ in care at level 2 or above and a plan that can be monitored and reviewed should be produced to show that most staff are working toward the qualification by an agreed date. 4 5 YA24 YA32 Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North West Region CSCI Preston Unit 1 Tustin Court Port Way Preston, PR2 2YQ 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 Bredon Respite Care Service DS0000070381.V361774.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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