Care Home: Valley View

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What the care home does well Service users were being provided with sufficient information about the Home in order for them, and their relatives, to make an informed decision about whether the service is right for them. They had individual and up to date plans of care which demonstrated that their health, personal and social care need were being met. A `person centred` approach was being taken to ensure that service users` individual needs and wishes were focussed on. The service provided activities and services that were based on individual needs and were valued by service users - promoting their independence where possible. Service users were receiving personal support in the way they required. Their health needs were being well met and they were being fully protected by the service`s procedures for dealing with medicines. Procedures for handling complaints and abuse were in place, ensuring that service users were fully protected. They were living in a homely and comfortable environment that was well furnished and maintained. The Home was clean but attention was required to the maintenance of laundry hygiene in order to safeguard service users` health. The service had a group of well-recruited and trained staff to ensure that service users were safe and their needs were met. The service was well managed so that service users were protected and their best interests were promoted by the systems in place. Two relatives who responded to the postal survey commented that "the Home has a warm and friendly welcome" and "They are superb". What has improved since the last inspection? New furniture had been purchased and there were new carpets in three bedrooms. Two bedrooms and the lounge had been redecorated and a new digital television purchased. Improvements had been made to medicine records, and to other recording systems, as well as to staff training. Certain health and safety issues had been addressed. Four of the five requirements, and ten of the twelve recommendations, made at the last inspection had been carried out. What the care home could do better: The service`s washing machine must have the specified programming ability to meet disinfection standards in order to maintain hygiene within the Home. CARE HOME ADULTS 18-65 Valley View Highfield Street Swadlincote Derbyshire DE11 9AS Lead Inspector Tony Barker Unannounced Inspection 23rd November 2007 09:15 Valley View DS0000020112.V354753.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 Valley View DS0000020112.V354753.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. Valley View DS0000020112.V354753.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Valley View Address Highfield Street Swadlincote Derbyshire DE11 9AS 01283 218076 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) www.unitedhealth.co.uk United Health Limited Ms Christine Looms Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Valley View DS0000020112.V354753.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2006 Brief Description of the Service: Valley View was opened in 2001 and is a purpose built home set in a large bungalow with gardens. The purpose of the Home was to provide accommodation to service users with substantial physical, sensory and learning disabilities. The physical environment of the Home was designed to a high standard and is spacious with specially adapted facilities. It was not designed to accommodate people with behaviours that challenge. Because of the levels of disability in the resident group, the Home offers an intensive package of support on a 24-hour basis with, accordingly, high staffing levels. The Registered Manager is a qualified nurse. Valley View DS0000020112.V354753.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 8 hours and was a key unannounced inspection. The Deputy Manager and one senior social care worker were spoken to. The service users had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed working with and being cared for by staff. Records were inspected and there was a tour of the building. One service user was case tracked so as to determine the quality of service from their perspective. Survey forms were posted to the relatives of five service users – three were returned; to six staff – five were returned; and one care manager, which was not returned. The information supplied in this way was analysed before the inspection and the outcomes included in the inspection process and reflected in this report. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection, Annual Quality Assurance Assessment (AQAA), questionnaire was reviewed prior to this inspection. The service’s fees were between £1600 and £1750 per week. A copy of the last inspection report, from the Commission for Social Care Inspection (CSCI), is available to service users and visitors and is kept in the office. What the service does well: Service users were being provided with sufficient information about the Home in order for them, and their relatives, to make an informed decision about whether the service is right for them. They had individual and up to date plans of care which demonstrated that their health, personal and social care need were being met. A ‘person centred’ approach was being taken to ensure that service users’ individual needs and wishes were focussed on. The service provided activities and services that were based on individual needs and were valued by service users - promoting their independence where possible. Service users were receiving personal support in the way they required. Their health needs were being well met and they were being fully protected by the service’s procedures for dealing with medicines. Procedures for handling complaints and abuse were in place, ensuring that service users were fully protected. They were living in a homely and comfortable environment that was well furnished and maintained. The Home was clean but attention was required to the maintenance of laundry hygiene in order to safeguard service users’ health. The service had a group of well-recruited and trained staff to ensure that service users were safe and their needs were met. The service was well managed so that service users were protected and their best interests were promoted by the systems in place. Two relatives who responded to the postal survey commented that “the Home has a warm and friendly welcome” and “They are superb”. Valley View DS0000020112.V354753.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. Valley View DS0000020112.V354753.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 Valley View DS0000020112.V354753.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were being provided with sufficient information about the Home in order for them, and their relatives, to make an informed decision about whether the service is right for them. EVIDENCE: Copies of a Service Users’ Guide and Statement of Purpose were displayed in the entrance hall as well as written reference to the availability of the latest Commission for Social Care Inspection (CSCI) inspection report in the office. The Service Users’ Guide did not provide details of the fees charged, as required by the amended Care Homes Regulations 2001. All the service users had lived in this Home for several years. A full assessment of the most recently admitted service user’s needs had been made prior to their admission, as confirmed by detailed examination of care records at the previous inspection. Valley View DS0000020112.V354753.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had individual and up to date plans of care which demonstrated that their health, personal and social care need were being met. A ‘person centred’ approach was being taken to ensure that service users’ individual needs and wishes were focussed on. EVIDENCE: The case tracked care plans were examined. These comprehensively covered the person’s assessed needs and numbered 19. There were 19 associated and well-worded risk assessments too. There was a sheet of staff signatures to provide an audit trail for care plan entries. Service user photographs were in place on care plan front sheets. One very brief incident of the case tracked service user ‘head banging’ had not been recorded on the Communication Sheet. The Deputy Manager said that not all staff had had training on record keeping and standards in this area were therefore not consistent. It was also noted that, although the quality of the daily records was satisfactory, entries did not reflect care plans and were mainly records of the person’s eating and sleeping habits – as at the previous inspection. Discussion took place with the Valley View DS0000020112.V354753.R01.S.doc Version 5.2 Page 10 Deputy Manager and senior social care worker over the benefits of encouraging staff to be proactive in their work through the active use of care plans and feeding back responses through Progress Notes or other regular recording system. The case tracked service user’s diary was found to be a useful person centred document and the person’s Life Story Book was also very person centred. Care plans were being regularly reviewed and appropriately recorded. The case tracked service user’s most recent formal annual care plan review notes were on file. None of the service users verbally communicated and staff were observed making use of a number of ways of understanding individual requirements, such as simple verbal prompts and gestures. The Deputy Manager said that no service user had a degree of comprehension sufficient to make choices – for example, between items of food or clothes offered by staff. She said that service users’ body language and individual reactions contribute to staff understanding of choices being made by service users. Service users’ wishes are identified, for example, by staff offering a variety of drinks until, after rejection, one is accepted. The Deputy Manager spoke of one service user having a large switch-board, in their bedroom, that can be used to turn music on and off. Although the service user tends to prefer staff to operate the switch the service user does make it clear to staff, by approaching them, of the wish to turn the music on and can also operate the device themselves. Service users’ files contained recorded risk assessments that indicated key areas of concern and ways in which staff can minimise or eliminate any problems in order to ensure individuals did not come to harm. The Deputy Manager gave examples of how service users were being enabled to take responsible risks – those risks that develop individual’s confidence and independence. She said, for instance, that the case tracked service user goes horse riding weekly – an activity that family strongly supports. Valley View DS0000020112.V354753.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service provided activities and services that were based on individual needs and were valued by service users - promoting their independence where possible. EVIDENCE: Five service users were attending day centres on a part time or full time basis. Other organised activities were based in, or from, the Home and run by the Activities Co-ordinator, who was employed from 7am to 4pm four days a week. It was clear, from talking to her at the previous inspection, that activities for service users were based on their preferences, where these had been identified. The case tracked service user’s Weekly Activities Timetable was seen and many of these activities took place in the Sensory/Activity Area between the dining room and lounge. It was noted, from discussion with the staff, that service users show that they find activities valuing and fulfilling by their facial expressions, laughter and enthusiasm, for example. Swimming and, particularly for one service user, the Home’s ‘Parker’ bath, were examples Valley View DS0000020112.V354753.R01.S.doc Version 5.2 Page 12 of such activities. One profoundly deaf service user had a board, to lie on, that transmits vibrations from music sources. This was an activity that caused the person to laugh and smile. Parties were held to celebrate annual events and external entertainers were brought in too. This aspect of the Home’s life was considered very positive by one relative who responded to the postal survey. The Deputy Manager and senior social care worker said that service users spend time at a number of local facilities, including shops, the pub, garden centre, swimming pool and hydro-therapy pool. The latter is located at a United Health house in Sheffield and all service users make use of it – with two going once a fortnight. The case tracked service user was spending half a day a week, with staff, at a local day centre’s disco in response to the person’s particular love of music. Service users had varying degrees of contact with their families. One service user, who has minimal family contact, is visited monthly by a key worker from the previous care home. One staff member commented, in their postal questionnaire, that the service “keeps the families of service users well informed if there are any problems or changes”. Several service users had basic self-help skills such as using the toilet and feeding themselves, with staff help. No service users were involved in any cleaning routines within the Home but all were involved in some weekly cooking sessions. Routines such as rising and going to bed were flexible unless a service user was attending a day centre. The service’s four week-rolling menu was examined and this indicated that service users were being provided with a varied and nutritious diet. Food stocks were examined and found to be satisfactory. They included fresh fruit and vegetables. Service users’ food preferences were recorded on a file in the kitchen together with nutritional information. Valley View DS0000020112.V354753.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were receiving personal support in the way they required. Their health needs were being well met and they were being fully protected by the service’s procedures for dealing with medicines. EVIDENCE: The senior social care worker gave examples of how staff ensure that service users’ privacy needs are met. Curtains and doors are shut when in bedrooms and bathrooms, she confirmed, and “all staff knock on doors” before entering. All service users but one use a wheel chair when going out. This maximises their independence. A toilet chair was currently being tried with one service user and this could eventually lead to greater independence, the senior social care worker said. New sensory lights in the sensory room had been provided. One service user had a hammock provided for their individual use in the lounge area. Five of the Valley View staff had been provided with external training in ‘Intensive Interaction’ and a physiotherapist had provided in-house training too. One service user was being provided with ‘Intensive Interaction’ at the day services attended and this had brought about improved behaviour. It was clear that staff practices were person centred in this service. One Valley View DS0000020112.V354753.R01.S.doc Version 5.2 Page 14 member of staff, in their postal survey, recorded that they felt the service “treats all clients as individuals”. An examination of care plans showed that service users’ health care needs were being met. A wide range of health professionals were, or had been, involved with service users. Each service user’s file contained Medical/Professional Appointment Communication Forms for recording health appointments and these were up to date. This system was an improvement from that seen at the previous inspection. Additionally, a clear ‘at a glance’ matrix was in place to record health appointments. The senior social care worker said that new protocols were in place regarding epileptic seizures for those service users affected. These protocols were followed, she added, in respect of two admissions to hospital. Service users’ medicines were being securely stored. The Medication Administration Record (MAR) sheets, relating to the case tracked service user, were examined and found to be satisfactory. A sheet of sample staff signatures and initials was in place to provide an audit trail. The case tracked service user was in receipt of three ‘prn’ (as-and-when-required) items of medication and the written protocols to address the use of this medication were well worded and designed. We were informed that the local epilepsy nurse had been involved in their design. No controlled drugs were in use. The Deputy Manager stated that all staff that administer medication had been provided with training on the safe use of medicines. Valley View DS0000020112.V354753.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures for handling complaints and abuse were in place, ensuring that service users were fully protected. EVIDENCE: The Home had a satisfactory complaints policy and procedure that was displayed in the entrance hall. The Manager reported, in the pre-inspection Annual Quality Assurance Assessment (AQAA), that there had been one complaint made, about the service, within the previous 12 months. The record of this complaint was examined and it had been dealt with in a satisfactory manner. Forms on which to record complaints, and their follow up, were well set out. The service was providing opportunity for visitors to the Home to record compliments about the service. The Deputy Manager confirmed that South Derbyshire Advocacy Service had supplied advocates for two service users to help them to exercise their rights – firstly with a solicitor and secondly at a care plan review meeting when the sponsoring local authority was unable to attend. The Company’s policies and procedures for safeguarding service users from harm were extensive and helpful. All staff had been provided with training on ‘Safeguarding Adults’ and the Deputy Manager reported that she had been the in-house trainer on this subject for the past two years. A written “Policy regarding Challenging Behaviour” was in place and the senior social care worker described good practice with regard to the way that staff address service users’ self harming behaviour. There had been one referral to the local Social Services Department, within the previous 12 months, regarding an Valley View DS0000020112.V354753.R01.S.doc Version 5.2 Page 16 incident of theft in the Home and the police had been involved. This had been recorded in the AQAA, by the Manager, but we had not been notified at the time of the incident. Valley View DS0000020112.V354753.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were living in a homely and comfortable environment that was well furnished and maintained. The Home was clean but the lack of appropriate laundry facilities has the potential to put service users’ health at risk. EVIDENCE: The Home was spacious and its corridors and rooms were large. It was well furnished and decorated and a number of environmental improvements had been made since the previous inspection. It contained a good range of equipment suited to individual service users’ needs. Bedrooms were very attractive and well personalised and contained a range of sensory equipment. Five of the eight service users had been provided with nursing beds in order to meet their assessed needs. These were seen to be relatively domestic in appearance. Four service users had shared access to two en-suite specialist bathrooms fitted with permanent hoists. The other four service users were provided with a bathroom with a specialist ‘Parker’ bath. An attractive sensory garden provided service users with opportunities to feel garden produce and Valley View DS0000020112.V354753.R01.S.doc Version 5.2 Page 18 smell plants. The garden also had a potting bench, with room for wheel chair users to sit under, and a swinging bench. The Home was situated near to the town centre of Swadlincote and it’s transport provided good access to local amenities. The service had a well-equipped laundry although the washing machine was not of an industrial type and did not appear to have a sluicing cycle. This was an important point given that all service users were doubly incontinent and had been noted at the previous inspection. The service’s Infection Control policy was satisfactory. The Manager had drawn up a written procedure on the ‘Disposal and Transportation of Waste’ and a risk assessment on the control of infection, which was displayed in the laundry room. All staff had undertaken, or were due to undertake, training in Infection Control. The Home was clean, at the time of the inspection, and it was noted that fresh bin liners had been in place before this inspection started. There were no unpleasant odours in the Home. Valley View DS0000020112.V354753.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service had a group of well-recruited and trained staff to ensure that service users were safe and their needs were met. EVIDENCE: 70 of the care staff – nine staff - had achieved a National Vocational Qualification (NVQ) to level 2 or above with a further four working towards this qualification. This met the National Minimum Standard to maintain a staff group with at least 50 qualified staff. The file of a member of care staff appointed in October 2007 was examined. It was found to contain all of the elements, required by current Regulations, regarding staff recruitment practices. A copy of the General Social Care Council’s (GSCC) Code of Conduct had been given to all staff. There was fully recorded evidence of this staff member being provided with induction training to Skills for Care Common Induction Standards. All staff had undertaken, or were due soon to undertake, mandatory training except that two staff had not been provided with recent fire training. The record of staff training was helpfully laid out in a training matrix. Valley View DS0000020112.V354753.R01.S.doc Version 5.2 Page 20 Three of the five staff, who completed the postal surveys, particularly mentioned the good standard of training in the service. Valley View DS0000020112.V354753.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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service was well managed so that service users were protected and their best interests were promoted by the systems in place. EVIDENCE: The Manager is a nurse with a learning disability qualification and 29 year’s experience of working with people with a learning disability. She had attained her Registered Manager’s Award at NVQ level 4. In addition to her management role she was sharing the role of key worker, of one service user, with another member of staff. The Home’s 2007 Annual Plan was examined. This was well worded and contained a wide range of goals with target dates against which to assess achievement. The senior social care worker said that the service was still circulating a newsletter to all visitors and supporters – the latest one being the Valley View DS0000020112.V354753.R01.S.doc Version 5.2 Page 22 Summer of 2007. This gave information about activities and events. Completed satisfaction questionnaires, with positive comments, from five relatives/advocates were seen although, with no dates, it was not clear when they were written. Staff opinions on the service are gauged through questionnaires although none were being sent to external professionals. Independent audit visits to the Home on behalf of the Registered Provider were taking place monthly, as required by the Care Homes Regulations, as evidenced by entries in the diary. However, there were no records of these visits available on the day of this inspection. The Deputy Manager said that the Provider undertakes a full audit of the services’ documentation every year. There was no evidence of the Manager regularly monitoring the quality of the service’s documentation, as discussed with her at the previous inspection and recommended then. Good food hygiene practices were being followed, including consistent recording of refrigerator and freezer operating temperatures. Cooked food temperatures were being adequately recorded and kitchen cleaning schedules were maintained. Cleaning materials were being appropriately kept in a locked wall cupboard in the laundry along with Product Information Sheets as required by the Control Of Substances Hazardous to Health (COSHH) Regulations. However, there were far more Product Information Sheets than there were associated products and this may, potentially, make finding the right Sheet difficult in an emergency. Portable appliances were being tested annually and the Home’s gas equipment too. The Environmental Health Officer had inspected the Home and made no recommendations, the Manager reported in the AQAA. Valley View DS0000020112.V354753.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 2 2 3 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 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Valley View DS0000020112.V354753.R01.S.doc Version 5.2 Page 24 Yes 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 YA30 Regulation 13(3) Requirement (Previous timescale was 01/05/07) Timescale for action 01/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard YA1 YA6 YA6 YA23 YA35 YA39 Good Practice Recommendations The Service Users’ Guide should at least indicate the range of fees charged, as required by the amended Care Homes Regulations 2001. Care plan recording practices should be improved. Daily records should reflect care plan goals. (This was a previous recommendation) Staff should be proactive in their work, as discussed at the inspection. The Commission should be notified of all events set out in Regulation 37, including theft within the Home. The two staff who have not received a recent fire training session should be provided with this training. Satisfaction questionnaires should be sent to external DS0000020112.V354753.R01.S.doc Version 5.2 Page 25 Valley View 7. 8. 9. YA39 YA39 YA42 professionals and all questionnaires returned should be dated. The records of monthly independent audit visits to the Home, on behalf of the Registered Provider, should be available within the Home, for inspection, at any time. The Manager should set up and operate a recording standards monitoring system. (This was a previous recommendation) Product Information Sheets, as required by the Control Of Substances Hazardous to Health (COSHH) Regulations, should be rationalised so that they reflect the actual products used. Valley View DS0000020112.V354753.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Valley View DS0000020112.V354753.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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