Inspection on 10/08/07 for 10 Spennithorne Road

This inspection was carried out on 10th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

10 Spennithorne Road 08/06/06

10 Spennithorne Road 14/12/05

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 10 Spennithorne Road 10 Spennithorne Road Urmston Manchester M41 5BU Lead Inspector Kath Oldham Unannounced Inspection 10th August 2007 08:45 10 Spennithorne Road DS0000064119.V340186.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 10 Spennithorne Road DS0000064119.V340186.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. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 10 Spennithorne Road Address 10 Spennithorne Road Urmston Manchester M41 5BU 0161 748 6414 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) Calderstones NHS Trust Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users have a learning disability and may in addition have an associated physical disability. The home should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 1 September 2006 Date of last inspection Brief Description of the Service: Spennithorne Road is a home for four residents with complex and multiple health and personal care needs. The home is located within easy reach of Urmston town centre, where residents are supported in taking part in community activities and the pursuit of individual leisure interests. The home is on one level, with access points in the kitchen and the front of the property. Ramps accommodate wheelchair users. There is off road parking to the front of the property and the large rear garden is accessed from French doors, leading off the lounge. The home’s inspection reports are made available to residents, families and professionals on request. A copy of the home’s Statement of Purpose and Service User Guide is available to read at the home. Fees are calculated on an individual basis based upon an individuals own financial circumstances and care package. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A random inspection was undertaken in September 2006, this being the previous inspection of Spennithorne. This visit was used to monitor how the service had developed from the previous inspection visit. This visit was unannounced, which means Spennithorne was not told we would be visiting, and took place on 10th and 15th August 2007, with a total of five and three quarter hours being spent on the premises. A key inspection looks specifically at all the Key National Minimum Standards and sees what the home is doing to meet them. Prior to the inspection Spennithorne completed a questionnaire that detailed some of the home’s actions to ensure the safety of people who use the service and is one of the ways the CSCI gathers information about the home. Comment cards were sent prior to the inspection for distribution to people living at Spennithorne. Comment cards were also sent to relatives. The views expressed in returned comment cards, where appropriate and applicable, and those given directly to the inspector are included in this report. Comments received after the report was completed will be included within the next inspection process. On the first day of the inspection visit, time was spent observing staff as they went about supporting residents. The building was inspected, as were a number of records, which related to the health and safety of residents and the running of Spennithorne. The care service provided to two residents was looked at in detail to help form an opinion of the quality of the care provided. On the second day the inspector spent time with the acting manager discussing and clarifying management matters and how the home is run. A brief explanation of the inspection process was provided at the beginning of the visit and time was spent on the second day providing verbal feedback to the acting manager. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Spennithorne has had a new adjustable bath fitted that meets the needs of the residents which was assessed by the occupational therapist. Spennithorne has also just ordered a new bath cradle for the specific needs of one of the residents. The acting manager explained that systems within Spennithorne have been reviewed and that a number of policies, procedures and practices have been, and will continue to be, developed to ensure residents have a consistent high quality service. An acting manager has been appointed and has been at Spennithorne since September 2006. It is the intention of Calderstones to propose the manager for consideration for registration with the Commission. All of the care workers if they have not achieved NVQ level 2 are working towards this. The acting manager is an NVQ assessor, so is able to support staff. Three of the support workers have NVQ level 2 and the deputy has nearly completed level 3. Four have completed underpinning knowledge and are working towards their level 2 and two are about to start in September 2007. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 7 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. 10 Spennithorne Road DS0000064119.V340186.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 10 Spennithorne Road DS0000064119.V340186.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The residents’ changing needs were assessed and recorded in order to ensure the staff continued to have the information that told them how best to meet residents’ individualised needs. EVIDENCE: No new admissions have taken place. The assessment of these standards was therefore not carried out at this inspection Procedures relating to the admission process were examined on previous inspections and demonstrated that information is provided to relatives to inform them about the services available to residents. 10 Spennithorne Road DS0000064119.V340186.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents have care plans in place and have their needs recognised and met. Recording systems require some development to enable Spennithorne to demonstrate that actual support is provided at the required times and frequency. EVIDENCE: All residents require a high degree of support in all aspects of daily living. This was clearly evident from records and observations of direct intervention and support provided by staff. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 11 All people who use the service have a written care plan in place. The information in care plans varied in content. There was good manufacturers’ information/guidance in place about procedures to be undertaken for such things as Percutaneous Endoscopic Gastrostomy tube (PEG) feeding equipment and the use of individual slings and equipment. PEG care plans were specific and identified individualised routines for practice such as feeding and medication, cleaning or the practice required to maintain PEG site. The care plans were focused on the health care needs of residents, as opposed to their social and personal care needs, so it was not clear what residents liked to do or when they liked to do things. By making improvements to the care plan, it would ensure the staff team always knew the right care they should provide to the residents. All comment cards said the home always helped their cared for resident to keep in touch with them and that they are always kept up to date with important issues affecting their cared for relative, for example, being admitted to hospital or if they have had an accident. All relatives said that the home gives the support to their cared for resident that they expect or have agreed. A relative indicated, that they felt that the “communication with me, keeping me informed of everything happening in my cared for relative’s life and listening to what I have to say about the care of my cared for relative” is something the home does well. Daily records were adequately completed, however more detailed recordings are needed if the home is to demonstrate the day-to-day life of each person, the support they receive, daytime occupation, and activities undertaken. Night time records detailed support provided, but it was unclear as to the times the support was given. Rising and preferred retiring times of residents were not routinely recorded. To ensure the needs of people are known and met appropriately, records should clearly detail the needs of people and how those needs should be and are met. The registered manager confirmed that all residents had received annual healthcare checks; the records detailed this. Where the home manages residents’ finances, records are maintained. Receipts for expenditure are retained and balance sheets record balances held as well as auditing routines. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 12 Current residents do not have the ability to fully communicate and for those that have some ability, communication is very limited and relates to basic immediate need. As a consequence, residents are not able to participate in the day-to-day running of Spennithorne or actively influence the development of the service. In order to ensure that residents’ views are, as far as possible, sought Spennithorne should secure independent advocacy services who act on their residents’ behalf. In response to the question, What do you feel the care home does well, a relative indicated that the home, “takes care of the service users, makes sure that they are well looked after. Making sure they go out and go on holidays. Also, as well as looking after them, the service users, seeing that the home they live in is clean and comfortable”. Residents have profound physical disabilities and are immobile and require assistance from staff. As a consequence, residents have support packages, which promote their safety but limit their experience in taking risks. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 ,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The aims and objectives of the home are to support residents requiring a high level of intervention in all aspects of daily living. EVIDENCE: The home supports individuals who require a significantly high level of support in all aspects of daily living. This is achieved through the support of residents in small, homely well-adapted bungalow. Spennithorne uses the key worker model of support. There is a clear emphasis on developing and maintaining social links with resources and public facilities, which meet residents’ needs. The home continues to have access to a minibus to support residents getting out to local centres and events. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 14 Staff support residents to access social and leisure interests inside and outside of the home. Individual care plans did not detail social routines and support provided to promote social involvement, hobbies or interests. Some records did indicate that one person liked classical music and the theatre but opportunities are not regularly provided to do this. Family members and friends are able to visit residents, as they desire. Staff continue to support residents on meal and menu planning, a number of residents are on prescribed peg feeds. There were ample provisions at Spennithorne; provisions are purchased weekly within the budget. Staff were observed supporting residents in a caring and sensitive manner. It was evident that residents were relaxed and recognised staff who were speaking to them. Most residents have specialised requirements at mealtimes, a number require support through PEG feeding routines, and others have soft and or semi soft diets. The menu offered appears somewhat basic. There was no indication of them being individualised, they did not indicate choices or that residents have access to or are offered nutritious snacks, treats or were able to have fresh fruit. The menu was not in a resident friendly format, which supports and/or encourages residents to make their own choice where possible. Staff take full responsibility for the preparation and serving of meals, including specialised diets. Whilst it was evident that staff had completed basic food hygiene training, it was not evident that they had completed training in the preparation of nutritious and specialised diets. It was unclear if they had knowledge of calorific values of food and were aware of the methods used to promote better health through nutrition. Additional training should be provided to those staff with responsibility for the preparation of meals and specialised diets. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are supported in all personal and health care needs in a way which respects their needs. EVIDENCE: All residents require support and intervention of staff on personal and health care needs. The level of health care support is detailed in care plans and monitored through Spennithorne’s review procedures. Residents appeared well dressed and clean. On the inspection, staff supported residents in a discreet and dignified manner. Residents’ care files identified that their general healthcare needs were recorded and monitored. Records of professional health care and support services were in place. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 16 All residents require assistance to take their medication, some of which is administered through the PEG tube. These records ensure that individual routines are known and that staff are aware of the procedures to be followed which can then be monitored. The aid to promote the mobility of a resident was questioned on the visit. Although it was understood that the aids used did support and maintain the resident’s independence, an alternative aid should be explored to support the resident’s dignity. Staff have had training in the administration of medication. This is a full day workshop and then a workbook is completed and updated yearly. Medication administration records were looked at and completed correctly. There was no indication of the practice undertaken when a resident is on social leave at the time of administration. Records should identify if medication was taken with them when they left the building. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Written complaints procedures ensure residents or their representatives have a means to raise views about the service they receive. Procedures and training on adult protection ensure residents are protected from abuse. EVIDENCE: The organisation has a written complaints procedure in place. From comment cards received, it is evident that relatives feel able to raise matters of concern and feel confident complaints will be dealt with appropriately. One relative said “If I have raised any concerns it is always reported to the highest authority”. Procedures relating to adult protection were in place. Comment cards indicated that relatives had confidence in the staff to protect their cared for resident. The indications from discussions with staff were that they had received training in protection of vulnerable adults. Spennithorne is advised to obtain the Local Authority Adult Protection procedures and retain documented evidence that all staff have read these procedures. 10 Spennithorne Road DS0000064119.V340186.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, 26, 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The design and layout of the home ensures residents live in a homely, comfortable and safe environment. EVIDENCE: The lounge is an adequate size and fitted with fixtures and fittings which promote a homely environment. Whilst the bungalow offers adequate communal space, residents would benefit from more communal living areas. Consideration should be given in the future to developing additional communal areas which would enable residents to have other places to sit and relax or join in activities. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 19 There is no office available for the acting manager or staff. Meetings have to be arranged within the lounge or dining room or in residents’ bedrooms with their permission. Meetings are also arranged outside of the home. Consideration should be given to developing designated office space within the home to enable meetings and private discussions to take place which do not impact on residents. A bed and mattress were propped up in the lounge awaiting collection. This compromises the safety of residents and unwanted equipment or furnishings should be removed in a timely manner. Bedrooms were suitably furnished and personalised by residents with the assistance of family and staff. The bedrooms were to be redecorated, along with the entrance hall, in the weeks after the inspection. Time has been spent ensuring that bedrooms are personalised and decorated to the individual person’s tastes. Overhead tracking is to be fitted in two of the residents’ bedrooms and electric plug sockets relocated to ensure they are in the right place. The rear garden is spacious and well maintained. Weather permitting, it was evident that residents did like to access the gardens. Laundry facilities were clean and of sufficient size to meet the needs and demands of Spennithorne. Washing machines have sluicing facilities which ensure that soiled items are appropriately disinfected and clean; all of which reduces the risk of cross-infection. Staff training records identified that staff have completed training in infection control procedures. 10 Spennithorne Road DS0000064119.V340186.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, 33, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Qualified staff that have clear set roles and responsibilities meets the needs of residents. The reduction in staff after 9.30pm restricts residents from having choice in retiring routines. EVIDENCE: Three staff members were on duty to care for four residents. All staff had received training in aspects of the residents’ needs, including gastrostomy care, first aid and manual handling. Further training was confirmed by the staff team, which exceeded the recommended minimum levels of five paid training days in a 12-month period. Staff spoke positively of the support offered to them in supervision sessions, staff meetings and in their own personal training plans. Staff commented that training was comprehensive and topics were relevant to meet their development needs. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 21 Staff assist in all domestic and catering duties, there are no designated ancillary staff. A cleaner comes into the home for two hours each week and contractors also come to Spennithorne to professionally clean carpets on a monthly basis. There were mixed responses in comment cards from relatives in relation to the question, “Do the care staff have the right skills and experience to look after people properly”, with one saying usually, one sometimes, and one responding always. One relative added, “One qualified person on duty every day ideally, if this is possible”. The manner and format in which the home compiles staffing rotas comply with correct standards. Full names of staff are included. First aiders were not identifiable; this needs to be arranged. To support and inform people who use the service, staffing rotas should be in a user-friendly format, which inform residents who is on duty and who will be coming on duty. Three or four staff were on duty during the day, dependent on the time. Daytime staff go off duty at 9.30pm. There is only one night staff on duty at Spennithorne, which means that residents have to be ready for bed before this time. This practice is restrictive to residents and additional staff should be on duty throughout the night to maintain residents’ choice and independence. There have been no staff appointed to Spennithorne since the last inspection. The recruitment and selection procedure was therefore not assessed on this visit. The acting manager said that staff are recruited using a thorough selection procedure with pre-employment checks carried out before commencement in employment. Thought is to be given on future recruitment of including residents in the selection process. Staff have responsibility for providing specialised support to residents, in that, they administer medication and food through the PEG tube procedures. The acting manager confirmed that staff had been trained and there was a training record to support this. All of the care workers, if they have not achieved NVQ level 2, are working towards this. The acting manager is an NVQ assessor, so is able to support staff. Three of the support workers have NVQ level 2 and the deputy has nearly completed level 3. Four have completed underpinning knowledge and are working towards their level 2 and two are about to start in September 2007. It is thought that the delay in reaching the 50 target is due to illness. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 22 Staff training records identified training. In addition to training identified within previous sections of the report, the majority of staff had received epilepsy training, all had received first aid, health and safety, communication or specialised training relating to supporting people with a profound disability. Staff receive supervision at the required frequency and attend staff meetings. The acting manager has received training in appraisals and supervision procedures. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The health, safety and welfare of residents are promoted and protected by the organisation’s management and administration procedures. EVIDENCE: The registered manager has been away from the home for some time due to ill health. The acting manager has been in post since September 2006. The acting manager said it was the intention of Calderstones to propose her to the Commission for consideration for registration as manager. The acting manager has nursing qualifications and is to commence the Registered Manager’s Award. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 24 The organisation ensures that Regulation 26 visits are completed each month, which means that someone from head office comes to Spennithorne and they consult with residents and staff about service provision and standards, look at records and discuss the running of the home with the acting manager. Copies of the outcome report need to be made available to the manager. The insurance displayed in the hall was out of date. The revised insurance certificate should be sent to Spennithorne by Head Office to ensure adequate and up to date cover. Staff demonstrated a clear understanding of the needs of each resident and commitment to support them. Policies and procedures are clearly written and discussed with staff during supervision and training sessions Information relating to fire protection indicated that the required weekly and monthly tests and checks were being carried out by the home. 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 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 2 X 3 3 X 3 X 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 2 Refer to Standard YA6 Good Practice Recommendations Care plans should clearly detail all the needs and support requirements of residents and how those needs are to be met. Records maintained should enable the home to demonstrate the day to day routines of individual people who use the service, including rising and retiring routines, care support provision, their achievements and successes and any activities undertaken. In order to ensure that residents views are as far as possible sought the home should secure independent advocacy services who act on their residents’ behalf. YA7 3 YA8 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 4 Refer to Standard YA17 Good Practice Recommendations The homes menu should detail all the mealtime options and alternative choices. A record of actual meals served. All nutritional assessments need to be detailed to inform staff about likes and dislikes and the way foods should be served. A system needs to be put in place that, wherever possible, enables residents to be consulted over meals. The recording in the menus needs to be changed to show to residents wherever possible what is on the menu. Explore alternative aids which are designed to assist and promote the residents abilities, mobility and dignity whilst promoting their independence Medication records and or related documents should clearly detail medication entering and leaving the building when people who use the service are on social leave. All staff should be trained in adult protection procedures including Local Authority procedures. Consideration should be given to developing designated office space within the home to enable meetings and private discussions to take place which do not impact on residents. Consideration should be given to developing additional communal areas, which would enable residents to have other places to sit and relax or join in activities. Arrange for items of furniture that are no longer required or are surplus to requirements to be removed from the house to ensure the risk to residents are minimised. All staff should be trained in infection control procedures, particularly where specialised support is being provided. Ensure that a written report is made of the monthly visits undertaken by the designated person from Calderstones, which is available to CSCI to evidence the consultation with residents and staff about service provision and standards, and the examination of records and discussions about the running of the home with the acting manager. 5 6 7 8 YA19 YA20 YA23 YA24 9 10 11 12 YA28 YA28 YA30 YA31 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 10 Spennithorne Road DS0000064119.V340186.R01.S.doc Version 5.2 Page 29 - 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!