Care Home: Chosen Court

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What the care home does well A robust and comprehensive admissions procedure ensures that the home is able to meet the needs of people moving in. People commented that "I had a look around a lot" and "I looked twice before I decided". Comprehensive care plans and risk assessments are in place, that are frequently reviewed to reflect people`s changing needs. Healthcare professionals stated "excellent care plans" and "care plans are comprehensive and regularly updated". People have access to a range of fulfilling activities both within the home and in the community. People`s wishes and choices are identified and wherever possible staff support them to achieve these. People said they "love swimming" and "going to the cinema". People have access to a range of healthcare professionals who expressed confidence in the staff and manager and the support provided to people living at the home. The home provides accommodation of a high standard that is regularly redecorated and well maintained. What has improved since the last inspection? A sun house in the garden has provided additional communal space for people where they can play pool or darts. What the care home could do better: Some improvements are needed in the way in which medication is administered, including the systems in place for taking medication on home visits. Complaints should be stored together with evidence of the outcome of any concerns that have been expressed. Behaviour management plans should clearly state that physical intervention is not used at the home. Ensuring that complete and full records are obtained for new staff prior to appointment will safeguard people from possible harm. The nighttime evacuation procedure must be reviewed to ensure that in the case of a fire people are protected from possible harm. CARE HOME ADULTS 18-65 Chosen Court 139, Hucclecote Road Gloucester GL3 3TX Lead Inspector Ms Lynne Bennett Key Unannounced Inspection 26 and 30th October 2007 09:00 th Chosen Court DS0000036066.V354103.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 Chosen Court DS0000036066.V354103.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. Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chosen Court Address 139, Hucclecote Road Gloucester GL3 3TX 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) 01452 616888 01452 616888 chosencare@btconnect.com Chosen Care Limited Miss Dawn Tracy Field Care Home 11 Category(ies) of Learning disability (10), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2006 Brief Description of the Service: Chosen Court provides accommodation for eleven people with a learning disability. The property is a large detached house in Gloucester close to local amenities. The house has a large garden to the rear of the building that is maintained to a high standard. There are five bedrooms with en-suite facilities on the ground floor suitable for people with a physical disability. The house has a further six en-suite bedrooms on the first floor. The Statement of Purpose and Service User Guide are kept in the ground floor office. Each person is given a copy. Fees for the home are negotiated according to each person’s individualised needs in agreement with the placing authority. Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection took place in October 2007 and included two visits to the home on 26th and 30th October. Time was spent talking with people living at the home and observing them in their day-to-day activities. Staff were also spoken with. The registered manager was present throughout the visits. The registered manager completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing information about the service and plans for further improvement. Four surveys were returned from people living at the home, four surveys from relatives and six surveys from healthcare professionals connected with the home. A range of records was examined including care plans, staff files, health and safety records and complaints information. What the service does well: A robust and comprehensive admissions procedure ensures that the home is able to meet the needs of people moving in. People commented that “I had a look around a lot” and “I looked twice before I decided”. Comprehensive care plans and risk assessments are in place, that are frequently reviewed to reflect people’s changing needs. Healthcare professionals stated “excellent care plans” and “care plans are comprehensive and regularly updated”. People have access to a range of fulfilling activities both within the home and in the community. People’s wishes and choices are identified and wherever possible staff support them to achieve these. People said they “love swimming” and “going to the cinema”. People have access to a range of healthcare professionals who expressed confidence in the staff and manager and the support provided to people living at the home. The home provides accommodation of a high standard that is regularly redecorated and well maintained. Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 6 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. Chosen Court DS0000036066.V354103.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 Chosen Court DS0000036066.V354103.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): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A comprehensive assessment of the person’s wishes and needs are taken into consideration before offering them a place at the home. EVIDENCE: Two people have moved into the home since the last inspection. The admission information for one person was examined. Comprehensive information was provided by the placing authority and from their former placement. The home had also completed an assessment prior to admission that provided a holistic assessment of their needs. There were records confirming the admission process that included several visits to the home and to the person in their previous placement. Before the person was admitted to the home a thorough assessment was completed providing the registered manager with sufficient information to make a decision about whether their needs could be met. The person said that they had settled into the home and had visited the home prior to moving there. Another person stated in a survey “I looked around and I liked it”. Chosen Court DS0000036066.V354103.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. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are being assessed and comprehensive care plans monitor and evaluate their changing needs. People are being supported to make decisions about their lifestyles. Risks are being managed safeguarding them from possible harm. EVIDENCE: The care of three people was case tracked which involved looking at their care plans, financial and medication records, talking to them and to staff about the care they receive and observing them during the visits. Each person has an assessment of activities of daily living which forms the basis of their care plans alongside care plans from their placing authorities. There was evidence that each person has an annual review of their needs that relatives and other people involved in their care attend. The home produces an extensive report backed up with supporting information for the review. Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 10 Comments from healthcare professionals included “ excellent care plans/planning” and “care plans are comprehensive and regularly updated”. Care plans were in place for a range of activities of daily living and there was evidence that staff were reviewing and evaluating these on a regular basis. Entries were well written and provided a clear record of the current status. Where appropriate care plans linked to risk assessments and behaviour observation charts. Additional monitoring charts were in place as appropriate and clearly relevant for each person. For instance a person who experiences seizures had comprehensive records in place keeping a check on their frequency and severity. Another person was being supported to manage their behaviour and behaviour observation charts evaluated incidents also referring to the use of “as necessary medication”. One such incident indicated that staff had not followed the care plan and risk assessment for a person which resulted in an incident. It was evident that both documents had been re-evaluated and action taken to ensure that staff were aware of the importance of following these guidelines. Staff were observed supporting people to make decisions about their daily lives. For example whether they wanted to participate in activities in the home or to help in the kitchen or go out for a drink. Regular house meetings were being held and records kept. People were being encouraged to discuss a wide range of issues about their home and meetings were also used as a way of passing on information about such things as new staff or changes to the environment. The registered manager confirmed that one person had an advocate and others have access to advocacy should they need it. Information about advocacy was displayed in one of the communal areas. Any restrictions to freedom or choice would be recorded in care plans. Assessments about whether people have a key to their room were included in these records. Individualised comprehensive risk assessments were in place with evidence of regular review. Generic risk assessments were also in place for the environment, use of transport and manual handling. Each person had a missing person’s proforma in place with a description and current photograph. Chosen Court DS0000036066.V354103.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): 12,13,14,15,16 and 17. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are able to make choices about their life style and supported to develop life skills. People have the opportunity to participate in social, educational, cultural and recreational activities that reflect their personal expectations. People are offered a varied and balanced diet appropriate to their needs, promoting their health and wellbeing. EVIDENCE: People were observed deciding where to spend their time and with whom. During the visits people were offered activities within the home such as music, preparing lunch, rug making, painting and watching a film. Other people went out to buy the daily newspaper from local shops, or went for a drink to a nearby pub. People had an activity planner that provided an outline of their scheduled activities for the week. People attend college courses and day centres on a regular basis. They said in the surveys that they were being Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 12 supported to go to the cinema, shopping, and swimming and to use a sun bed. Surveys from healthcare professionals commented that people were “ well supported in choosing the activities they would like to be involved in and are supported in accessing activities” and there were “good structured activities”. Staff confirmed that there were sufficient staff to support people to complete their scheduled activities and that they had access to several vehicles as well as walking to local facilities and using public transport. Care plans identified each person’s choice of religion and daily diaries and activity schedules confirmed that they were being supported to go to church each Sunday. People were being helped to maintain close links with families and friends. During one visit staff had helped people to write letters. Another person was planning to go home for the weekend. Comments from relatives included “ when we visit staff are very friendly and make us very welcome” and “staff are very supportive”. People’s likes and dislikes were indicated in their individual care plans. People were observed choosing where to spend time and with whom. Several people said that they did not wish to attend the music session and chose to either spend time in their rooms or with staff. Staff were observed treating people with dignity and respect. A healthcare professional stated, “ I have always found this home to be aware of the issues and respectful in the different needs of residents”. People were observed helping around their home. One person was helping with lunch and others with clearing up. People living at the home said they clean their rooms and clean the house with the support of staff. Some people like to do gardening and also to help with the shopping. Staff confirmed that people were being involved in menu planning in the home. Menus for a four-week period were sampled providing a range of nutritional and healthy meal choices. Two people have soft diets and alternative menus were being produced for them. There was evidence of regular consultation with a Speech and Language Therapist and a dietician. Where there were concerns about the diet of people comprehensive dietary records were being maintained. There was evidence of fresh fruit being available and there were good stocks of fresh vegetables and salad ingredients. Chosen Court DS0000036066.V354103.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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health and wellbeing are being met helping them to stay well. There are some improvements in the administration of medication that need to be implemented to safeguard people from the risk of error or possible harm. EVIDENCE: Outcomes in some areas of personal and healthcare support were excellent but some improvements were needed in the administration of medication affecting the overall judgement for this area. The way in which people would like to be supported was clearly recorded in their care plans. Each person had a pen picture providing staff with a summary of their personal and healthcare needs. People’s preferences for the gender of staff providing their personal support was not recorded in care plans. Records confirmed regular contact with the local Community Learning Disability Team. Feedback from healthcare professionals was very positive, “staff understand their needs well and communicate with me (health professional) and the Community Learning Disability Team appropriately” and “ they liaise Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 14 with health professionals and inform the team of any issues”. Records indicated that any concerns were being followed up promptly and action taken to ensure that people received the input they required. The registered manager stated that health action plans had been put in place for a couple of people and others would be developed. These were not seen during this inspection. Care plans and copies of reviews confirmed that where needed the care programme approach was in place with regular reviews in a multi agency forum ensuring that the mental health needs of people were being met. Robust and clear healthcare records were in place providing evidence of regular contact with a range of healthcare professionals including their doctor, district nurse, dentist, chiropodist and optician. After each appointment a summary of the outcome was being recorded. The home had supported a person through poor health, liaising with district nurses and other professionals ensuring that the appropriate equipment was provided where needed. A healthcare professional commented that they “met the needs of a person who should have moved to nursing care but facilitated exceptional care with health support”. Systems for the administration of medication were examined. Staff confirmed that they attend a monitored dosage awareness course. Additional training in the safe handling of medication should be made available. Medication was observed being given to people and this was done appropriately with safe practice being followed. The following issues were identified as needing to be addressed: • • • • Secondary dispensing of medication was taking place for one person going home Handwritten entries on the administration record were not being initialled or countersigned Liquids were not marked with the date of opening Homely remedies had been authorised by the Doctor in 2005. Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 15 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 the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable people to express their concerns and they are confident that they will be listened to. People are safeguarded from possible harm or abuse. EVIDENCE: The home has a complaints policy and procedure. People living at the home have a copy in their personal file. Minutes from a recent house meeting confirmed that staff talk through the complaints procedure to remind people of the process. People spoken with said they would talk to staff or the manager. Surveys confirmed this. Two complaints had been received from people living at the home over the past twelve months. The registered manager found information about one of the complaints but was unable to locate the other. A complaints folder was in place but the information had not been stored there. There was no evidence of the outcome of the complaint. The registered manager said that this had been resolved and that the action taken had been recorded in the message book. Staff confirmed that they had attended training in the safeguarding of adults and those spoken with had a satisfactory understanding of the issues around abuse. They were all confident that any poor practice would be challenged and dealt with by management. The registered manager confirmed that she had obtained information about the Mental Capacity Act and that she was due to complete training to cascade to staff. Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 16 The registered manager stated that staff had completed training in the management of challenging behaviour. Some new staff had also completed training in the use of physical intervention with previous employers. She had provided this training to some new staff but they had since left the home. Staff indicated that there had been use of physical intervention on one occasion when the use of diversion and distraction had failed. The registered manager stated that physical intervention was not used in the home. Behaviour management plans were in place giving staff guidelines about triggers and the support they were to provide. These should clearly state that physical intervention is not to be used. Comments from healthcare professionals indicated that the home had worked closely with them and that people “ with a wide range of abilities, problems and behaviours (live there) and the home has managed them all very well”. Robust financial records were in place for each person. Records confirmed expenditure and could be cross-referenced with numbered receipts. Regular checks were seen to be in place by the registered manager. Several people have bank accounts that they were able to access with minimal support from staff. Chosen Court DS0000036066.V354103.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 the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people to live in a wellmaintained and comfortable home that encourages independence. EVIDENCE: Chosen Court provides accommodation of a high standard that is regularly maintained and redecorated. Each person has a room with en suite facilities and access to an additional bathroom on the first floor. People have personalised their rooms to reflect their interests and lifestyles. The addition of a summerhouse in the garden that was being used as a games room adds to the already spacious communal areas in the home. People were observed making good use of the conservatory and lounge. Records confirmed that they were being encouraged to help to care for their home, cleaning their rooms and helping with the gardening. One person said “I love to do my cleaning”. Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 18 A walk around the environment confirmed that the home was pleasantly decorated with good fixtures and fittings. The gardens were also well maintained. Staff confirmed that two domestics have been employed to ensure that the home is clean. At the time of the visits the home was clean and tidy. Laundry facilities provided hand-washing facilities with liquid soap and paper towels. Personal protective equipment was provided and hazardous products were stored correctly for which data sheets were in place. Colour coded mops and buckets were observed being used. Chosen Court DS0000036066.V354103.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): People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are met by a competent staff team, who have access to a satisfactory training programme that provides staff with knowledge about the diverse needs of people living at the home. Improvements in recruitment and selection procedures will ensure that people are being safeguarded from possible harm. EVIDENCE: The staff team have a mixture of skills and experiences with most having worked in this area of care for a number of years. New staff confirmed that although experienced in care they completed an induction programme with the home and shadowed existing staff for two weeks. Each new member of staff is given an employee handbook and evidence was provided that they have read these. The registered manager stated that staff have a probationary period of six months before being confirmed in post. Staff said that a NVQ programme was in place in the home. The AQAA confirmed that 50 of the staff team have or were working towards a NVQ Award. Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 20 Staff were observed treating people with dignity and respect. Those spoken with had a good understanding of the needs of the people they support. Staff said that the registered manager was a positive role model. She was firm and clear to staff about her expectations of them and their roles and responsibilities. A healthcare professional commented “I have the utmost confidence in the care delivered by staff at Chosen Court”. Recruitment and selection files for three new members of staff were examined and these were found to be mostly satisfactory. The following issues were identified as needing action: • The reason why people left former positions in care working with adults or children had not been obtained – the reference request form was changed during the inspection to request this information from former employers Staff were being employed upon receipt of a povafirst check – evidence of this was being obtained and kept electronically – this information was later printed and stored on each individual’s files. There was no evidence that a risk assessment was in place for staff starting work without a CRB check. The registered manager said that staff had restricted duties and were shadowing existing staff until it was obtained. CRB checks were being kept on staff files. These need to be kept separately. All checks for current staff can now be destroyed. The registered manager described the process for checking and validating references. This should be recorded. • • • A training matrix was in place confirming that staff have access to mandatory training and other training specific to the needs of people living at the home such as epilepsy, dementia, incontinence and diabetes. Staff confirmed that they complete refresher training when needed. Chosen Court DS0000036066.V354103.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): People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home which is run in their best interests offering them choice, respecting their wishes and keeping them safe. EVIDENCE: The registered manager has 17 years experience in care and has completed all relevant qualifications. Comments from healthcare professionals indicated this is one of the best homes in Gloucester and that “the home manager advocates strongly on behalf on the clients”. The registered manager had a proactive approach to this inspection taking on board any issues and where possible rectifying them during the visits. A quality assurance system needs to be established that places people living at the home at the heart of the system. The registered manager stated that they Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 22 had previously taken part in surveys and that house meetings provided an opportunity for review and reflection on the service being provided at the home. The AQAA identified several areas for improvement and this could be used as part of the improvement plan for the home. Systems for the monitoring of health and safety within the home were seen to be in place. Good food hygiene practice was observed in the kitchen with temperatures being recorded on a regular basis for cooked foods, water, fridges and freezers. Fire records were in place providing evidence of regular monitoring of fire systems. Staff complete regular fire training. A fire risk assessment was in place. This needs to be reviewed in light of the Regulatory Reform (Fire Safety) Order 2005. The nighttime evacuation procedure referred to people with mobility problems staying in their rooms until the fire service arrives. This contravenes the Order which states that a full evacuation must be in place unless people cannot be moved due to their complex needs. Chosen Court DS0000036066.V354103.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 X 2 4 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 4 25 X 26 X 27 X 28 X 29 X 30 4 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 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 X 3 X 2 X X 2 X Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13(2) Requirement Staff must not put medication into compliance aids. This is secondary dispensing and puts people at risk of possible harm due to medication errors. Staff must initial any handwritten entries on medication administration records. Liquids must be marked with the date of opening. This is to safeguard people from possible harm. Before appointing new staff written verification of the reason they left former positions in care must be obtained. This is to safeguard people from possible harm or abuse. A quality assurance system must be put in place that takes into account the views of the people living at the home. This is so that people are involved in the review of the service they receive. The fire risk assessment must comply with the Regulatory DS0000036066.V354103.R01.S.doc Timescale for action 09/11/07 2. YA20 13(2) 09/11/07 3. YA34 19(4) Sch 2.4 09/11/07 4. YA39 24 31/03/08 5. YA42 23(4A) 30/11/07 Chosen Court Version 5.2 Page 25 Reform (Fire Safety) Order 2005. This is in regard to the evacuation procedure. 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. 4. 5. 6. 7. 8. Refer to Standard YA18 YA20 YA20 YA22 YA23 YA34 YA34 YA34 Good Practice Recommendations People’s preferences for the gender of staff providing care to them should be recorded. Staff should have access to more comprehensive training in the safe handling of medication. The homely remedies list should be reviewed with the doctor to take into account any changes in medication. Complaints should be logged on the complaints file and the action taken as a result of the concern should be recorded. Behaviour management plans should clearly state that physical intervention is not to be used. A risk assessment should be put in place for staff starting work without a CRB in place. CRB checks should not be kept on staff files. Where references are validated and checked, this information should be recorded. Chosen Court DS0000036066.V354103.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Chosen Court DS0000036066.V354103.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!