Care Home: Montrose Barn

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What the care home does well What has improved since the last inspection? This is the first inspection. What the care home could do better: No statutory requirements were identified at this inspection. Some recommendations were identified to further improve on current practice. These are as follows: if there are costs that the individual needs to pay as well as their benefit entitlements, these should be included in the contract. A policy and procedure should be introduced in the management of people who use the service moneys. In addition it is recommended that a second person audits the monies on a regular bases to ensure that the system is safe and people who use the service monies are protected. The registered person should continue to develop Montrose Barns` policies and procedures so that they are appropriate to the home and inform, guide and direct staff in what actions are expected of them. We would like to thank the People who use the service, staff, registered person and those who completed surveys for their kind assistance during this inspection process. CARE HOME ADULTS 18-65 Montrose Barn Rose-In-Vale St Agnes Cornwall TR5 0QE Lead Inspector Lynda Kirtland Unannounced Inspection 15th May 2008 09:10 Montrose Barn DS0000071116.V364402.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 Montrose Barn DS0000071116.V364402.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. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Montrose Barn Address Rose-In-Vale St Agnes Cornwall TR5 0QE 01872 553059 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) angie.salunke@btinternet.com Personal Address in Former Addresses Mrs Angela Prakash Salunke Mrs Angela Prakash Salunke Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Montrose Barn DS0000071116.V364402.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 2. Date of last inspection First inspection Brief Description of the Service: Montrose barn is a care home providing accommodation and care for up to two adults with a learning disability. The registered provider is Mrs Angie Prakash Salunke who has many years experience in managing care homes. Montrose Barn opened in January 2008 and is being set up as a home where people who already have a reasonable level of independence can continue to develop their personal and social skills. The home is located in the village of Rose In Vale, approximately 5 miles from the town of St Agnes and Perranporth. The home has a vehicle to provide transport for people who use the service who need to access resources in the wider community. The premises is divided into two, with one part belonging to the registered provider and the attached wing providing the accommodation for people who use the service so that they and the registered provider can be apart when not working together. This also allows the registered provider who undertakes the sleeping in duties at night to be within close proximity to the people who use the service when needed. The home is a two-storey building. All the bedrooms have en suite bathroom facilities. On the ground floor are the communal lounge, kitchen/diner and one bedroom, en suite. On the first floor are one bedroom, en suite and a separate bathroom. There are extensive gardens, and parking space at the front of the home. The registered provider stated that the current range of fees is in the region of £1000 to £1700 per week. People who use the service s are responsible for purchasing personal items such as toiletries. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Montrose Barn opened in January 2008 and this was the first key inspection, which took place on 15 May 2008 and lasted for approximately seven hours. The purpose of the inspection was to ensure that people who use the service needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus is on ensuring that people’s placements in the home result in good outcomes for them. Information received from and about the home since it’s opening has also been taken into consideration in making judgements about the quality of outcomes for the people living there. The inspection included meeting with the people who use the service currently living at Montrose Barn. Other activities included an inspection of the premises, examination of care, safety and employment records and discussion with the staff and registered person. We talked to the people using the service, and asked staff about those people’s needs. We also looked at the care plans, medical records and daily notes for these people. This is called case tracking. There were opportunities to directly observe aspects of peoples daily lives in the home and staff interaction with them. Due to the home offering care and support to two people, to respect confidentiality examples of care or quotes will not be provided in this report. However it is to be noted that we received surveys from the people who use the service, a relative, two staff members and a health professional. The overall view from these surveys was that Montrose Barn provides ‘excellent’ care and that all were satisfied with the care received, level of activities, staff skills, accommodation and food. The Commission received the Annual Quality Assurance Assessment, which is a questionnaire that the registered person completed. The AQAA describes the services and facilities that Montrose Barn provide and identifies what areas they do well in and where they want to make further improvements. The conclusion of the inspection is that all the care standards receive a good or excellent rating. As this is the first inspection the maximum overall rating the home is able to achieve is good which Montrose Barn has certainly achieved. What the service does well: It was evident from looking at documentation, talking with people who use the service and a tour of the home that there was a planned moving in period to Montrose Barn. People who use the service said that they choose the décor of their rooms. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 6 People who use the service were each provided with written and pictorial information about the home. The home operates like a shared domestic dwelling with staff support provided where it is needed to assist them to develop and maintain their skills and independence. Assessments prior to moving into Montrose barn are undertaken and based on the individuals health, social and personal care needs, including needs relating to their religious, ethnic and cultural backgrounds, to ensure they can be met in the homes setting. People who use the service are encouraged and supported to develop their skills and independence in many ways. They are involved in developing their own care plans with assistance and support from staff. They attend reviews so that they know why they are placed at the home and via their person centred planning process identify what aspirations they are aiming to achieve e.g. developing a particular element of self-care to promote their skills and independence. They have opportunities to make decisions about important aspects of their lives, with assistance from staff, if they need it and are supported to take risks so that they can enjoy fuller and more active lives in and out of the home. Access to health care is appropriate for the individuals needs and the medication systems in the home are robust so that the risk of medication errors is to a minimum. Montrose Barn has a daily photo dairy that is produced by the people who use the service and staff. This clearly evidences what activities they have completed on a daily bases both in and outside of Montrose Barn. People who use the service have clear information on what is expected of them and their rights as residents of a care home. They are aware, for example, that they will be expected to help out with household tasks such as cooking and cleaning, so that they can develop their skills and independence and know what to do if they wish to make a formal complaint about something they do not like. People who use the service participate in the ‘food shop’ and were observed to make choices of what to have for lunch during the inspection. They have free access to the kitchen so that they can make drinks and snacks for themselves when they wish and are encouraged to live and eat healthily. People who use the service are appropriately supported with their personal care so that they maintain their dignity. Staff were observed to assist them with their needs quietly and unobtrusively. The registered person is booked to attend multi-agency training in the protection of vulnerable adults from abuse to enhance their knowledge and skills of working together with key agencies involved in this. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 7 Montrose Barn is decorated and furnished to a good standard throughout. People who use the service were consulted about the décor and furnishings so that the home is personalised to reflect their tastes and preferences. It was clean and tidy throughout. The staff team demonstrated throughout the inspection positive interactions with people who use the service and assisted them with personal care needs in a discrete manner. Staff have had a comprehensive and valuable induction to the home. Staff confirmed access to training is available. The registered provider is aware and will ensure that all events notifable under regulation 37 of the care Standards Act 2000 must be reported to the Commission as per legislation The inspector was welcomed to the home in a friendly manner by staff and People who use the service. All were aware of the reason of the inspection. 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. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service needs are assessed prior to their admission so that they can be confident it will meet their health, personal and social care needs, including needs relating to their age, religion, cultural and ethnic backgrounds, abilities, gender and sexual orientation. EVIDENCE: From observations and talking with People who use the service it was evident that they are settled in the home, and that they get on well with each other and with the staff. A copy of the home’s statement of purpose is on display and the Service Users Guide is placed on the individuals file. This is presented in written and pictorial formats. From documentation inspected it was evident that admissions are made following a full assessment and in consultation with the individual, their family or advocate, and relevant professionals. Transitional work for the person moving into the home was undertaken in a planned manner and at the persons pace. Contracts in relation to the placement identify individuals’ rights and what services they will be provided with. It is recommended that if there are costs that the individual needs to pay as well as their benefit entitlements, these should be included in the contract. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9, 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service are aware of their care plans, which fully address their health, personal and social care needs, including needs relating to their individual and diverse backgrounds (age, religion, culture and ethnicity, abilities, gender and sexual orientation). They are able to take safely managed risks and make important decisions about their lives so that they develop their skills and independence. EVIDENCE: People who use the service, their family, advocate and relevant professionals are involved in the development of individual care plans and their subsequent reviews. The care plan has specific headings to address their health, personal and social care needs, including their individual and diverse needs. These are in written form. Care plans provide people who use the service with specific goals to work towards, and inform and direct staff in how to support the individual to achieve this goal to encourage them to fully maximise their skills for independent living. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 11 People who use the service participate in making decisions about important aspects of their daily lives, according to their individual abilities and this was observed during the inspection. There are also formal meetings held each month so that they can discuss issues and make household decisions as a group. Staff were observed supporting individuals who required it, to make decisions about what to do during the day. People who use the service written care plans formally consider their abilities to make decisions for themselves and daily care records provide further evidence of the choices they make in their daily lives. Residents can choose the level of privacy they wish to enjoy in their private accommodation. Residents are able to take managed risks, backed up with written risk assessments and risk management plans, particularly with regard to their engagement in higher risk activities. Montrose Barn DS0000071116.V364402.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): 11, 12,13,14,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service are able to take part in a wide range of activities in and out of the home, which are appropriate to their ages, individual needs, interests and cultural backgrounds so that they develop their skills and confidence. They are supported to maintain valued social and family relationships so that they are not isolated or institutionalised. They are informed of their rights and responsibilities so that they are aware of what is expected of them. They are provided with a wholesome and varied diet so that they enjoy their meals and stay healthy. EVIDENCE: Individual care plans, photo dairy and daily care records provide good evidence that the persons interests and abilities are fully considered in planning their daily activities, which are planned with them individually. This is written up as a guide but as was observed during the inspection, when an individual said they did not want to do the planned activity, another one was negotiated which Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 13 they then participated in, and on return to the home it was evident that all had an enjoyable time. Some activities include attendance at college, clubs, cinema swimming, and walks, attending religious services, and pub lunches for example. A daily photo dairy produced by the individual and staff demonstrate the level and range of activities that they participate in. At the time of the inspection People who use the service were engaged in a variety of different and appropriate activities in and out of the home, with staff support provided as necessary. In addition daily care records show that they access a wide range of community resources with staff support, depending on their individual needs and abilities. People who use the service are encouraged to maintain valued relationships with their families and friends, with staff support as necessary, which was observed at the inspection. In addition their photo dairies and daily care records, discussion with visitors, plus surveys from people who use the service and relative confirmed this. People are able to make telephone calls in private if they wish. People who use the service are supported and encouraged to eat healthily. They undertake shopping, planning for and preparing meals with assistance from staff. Observations of people who use the service were seen to choose what they wanted to have for dinner, where they wanted to eat it (chose the garden as sunny day, this was a relaxed and social occasion) and afterwards washed and dried the dishes. Nutritional needs and preferences are considered as part of the care planning process. People who use the service looked healthy and well nourished. The home has an ordinary, domestic kitchen, which they can access freely, to prepare drinks and snacks when they want them. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service personal and healthcare needs are well met so that they are able to live full and active lives in and out of the home. Medication systems are robust so that People who use the service health needs are managed safely. EVIDENCE: Care plans address their individual personal care needs and with sufficient bathroom facilities the person is able to attend to their personal care privately. Healthcare needs are considered as part of the care planning process and regularly reviewed. In discussions with people who use the service and documentation showed that they access external healthcare providers, including specialists, when they need to. The registered person has consulted with a pharmacist who has agreed to supply individual lockable medication cabinets for people who use the service use. A controlled drugs book is also on order. The registered person is currently reviewing the homes medication policies. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 15 People who use the service records provide evidence that they access a range of local NHS healthcare providers on a regular basis so that they maintain good physical health and emotional wellbeing. The registered person described how the home links with local specialist services to assist people with specific behavioural and emotional needs and regularly consults with external professionals to ensure their needs are managed effectively and appropriately. All staff that handles medication are appropriately trained and there are certificates to provide evidence of this. Medication records were satisfactory and a tablet count of medication tallied with records kept in the home. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are listened to and respected so that their views, concerns and complaints are taken seriously and acted upon. There are formal and informal systems in place to ensure that they are able to feel safe in the home EVIDENCE: People who use the service were encouraged to speak to the inspector if they wished so that they could make their views known or raise any concerns. No concerns were raised. People who use the service are aware of how to raise any concerns and Montrose Barn has a formal complaints procedure and informal opportunities (e.g. house meetings, care plan reviews and 1:1 time) to raise any concerns with staff before they become serious complaints. The home has received compliments from family members and professionals since opening and no complaints. The registered person is aware that the homes safe guarding and whistle blowing policies need to be reviewed and changes to improve these documents were discussed. All staff have undertaken some safe guarding training at different levels, with one person attending the multi disciplinary safeguarding course (and the policy was present in the home). The staff team knowledge of safeguarding issues is sound. The registered provider is booked to attend the Multi Agency Safeguarding (investigators) course to enhance her knowledge further. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 17 From inspecting people who use the service monies it was recommended that a policy and procedure should be introduced in the management of their moneys so that staff are aware of what procedure they need to follow if they are involved in any purchases, or deposits on behalf of the individual and how to record this. In addition it was recommended that a second person audits the monies on a regular bases to ensure that the system is safe and people who use the service monies are protected. The registered provider has now implemented both of these processes. There are records to show that staff are recruited on the basis that they are suitable to work with vulnerable adults in a care setting and appropriate checks are made. People who use the service are not isolated in the home, but take part in a range of activities in the local community and have relationships with people from outside of the home that they can communicate serious concerns to. Montrose barn has a whistle blowing policy. Montrose Barn DS0000071116.V364402.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): 24,25,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s environment provides People who use the service with an ordinary, domestic setting so that they can develop their skills and independence in a non-institutional setting. Consultation with People who use the service has led to communal and private space being furnished to a comfortable and high standard. It is safe and clean so that People who use the service are protected from risks of cross-infection. EVIDENCE: From a tour of the home by the registered person and people who use the service it was observed that the home was furnished and decorated to a good standard throughout. People who use the service confirmed that they helped with the choices of furnishings in the home and were particularly pleased with their en suite bedrooms that they had personalised, which were attractively furnished. Suitable equipment to promote independence has been gained following consultation with relevant health professionals. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 19 The registered person has completed environmental risk assessments to ensure that the premises are safe. Staff were aware of COSHH and relevant lockable storage was in place to store these items. Staff have attended infection control courses. Montrose Barn DS0000071116.V364402.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): 32,333,34,35,36 . Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of qualified staff on duty so that people who use the service can have confidence in their competence and skills. Staff training is encouraged so that up to date research and knowledge can be gained for the benefit for the people who use the service The home’s recruitment policies and practices are fair, safe and effective so that people who use the service can be assured that staff are suitable to work in a care setting. Staff receive regular, formal supervision. EVIDENCE: In discussions with people who use the service and staff, plus surveys, all felt that there were sufficient staff on duty at all times. During the week there are a minimum of two staff on duty, at the weekends there is one member of staff plus the registered person on call. The registered person is the nominated sleeping in member of staff at night. Care staff undertakes all personal care duties plus with people who use the service assistance cleaning and cooking tasks. From observations of staff interaction with People who use the service it was evident that they Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 21 communicate with them in a competent, fair, patient manner and work with them at their pace. This is a new staff team and all spoke positively about their recruitment, induction, and access to training and management support. There has not been a need to employ agency staffing. The staff team are experienced in working in the area of learning disability. Two staff members have achieved NVQ level 4, and one is in process of, and one has completed the Registered Managers award and another has a health and Social Care degree. Access to training courses such as medication, health and safety, infection control, manual handling has occurred. The registered person is an accredited trainer in some of these fields and is able to cascade the training to staff. The home’s staff recruitment records indicate that staff are appointed on the basis of written application forms and equal opportunities interviews. Appropriate checks are made of their suitability to work with vulnerable adults in a care setting. People who use the service were aware of recent interviews and met with the applicants. Staff, confirmed by documentation, stated that there is regular formal supervision. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The registered person is qualified and experienced to run a care home. The home is well run for the benefit of People who use the service. There are formal and informal systems in place to ensure that People who use the service views are accounted for in the day-to-day running and ongoing development of the home. The development of policies and procedures is ongoing. There are systems in place to protect service users from avoidable harm and injury. EVIDENCE: Angela Prakash Salunke has the skills and competence to manage a care service effectively. She has previous experience of managing a care home, to which the rating under her leadership improved to that of an ‘excellent’ service. She ensures that her training is up to date so that her knowledge and skills base is increasing to the benefit for people who use the service. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 23 Staff and People who use the service spoke highly of Ms Salunke’s skills and felt that she was approachable and listened to their ideas or concerns. From observations, all interacted with her in a relaxed manner. As the service is new Mrs Salunke has introduced a questionnaire for all visitors to the home to complete. This will then be incorporated in her quality assurance process. Views from People who use the service, family and staff are being sought as the home is in the early stages of its development. Records are stored confidentially, and recordings adhere to the data protection act. Advise was given to clarify when to notify the Commission of particular incidents under regulation 37 so that in future all incidents are reported. Mrs Salunke is also aware and is working on improving her polices and procedures so that they are appropriate to the service she provides and inform and guide staff accurately as to what is expected of them. The home’s environment appeared safe and there are written individual and environmental risk assessments in place to minimise risks to people who use the service and staff working in the home. Maintenance of the home and its equipment are satisfactory. The home’s fire safety records were completed and up-to-date. There are records of regular tests and checks of safety equipment and procedures in the home to ensure People who use the service, staff and visitors safety. An independent consultant has undertaken fire training with staff and gave advice in respect of the homes fire risk assessment to ensure that it is in line with the new legislation. Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 4 33 4 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 3 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x 3 4 X 2 2 3 x Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 YA5 Good Practice Recommendations It is recommended that if there are costs that the individual needs to pay as well as their benefit entitlements, these should be included in the contract. The registered person should continue to develop Montrose Barns’ policies and procedures so that they are appropriate to the home and inform, guide and direct staff in what actions are expected of them. 2 YA40 Montrose Barn DS0000071116.V364402.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West 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 Montrose Barn DS0000071116.V364402.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. 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