Inspection on 08/06/06 for 10 Spennithorne Road

This inspection was carried out on 8th June 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10 Spennithorne Road 10/08/07

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 3BY Lead Inspector Michelle Moss Unannounced Inspection 8th June 2006 12:40 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 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.V287621.R01.S.doc Version 5.1 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.V287621.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 10 Spennithorne Road Address 10 Spennithorne Road Urmston Manchester M41 3BY 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) sandra.hodgins@calderstones.nhs.uk Calderstones NHS Trust Sandra Hodgins Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 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. 14th December 2005 Date of last inspection Brief Description of the Service: Spennithorne Road is a home for 4 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 cellar, 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 resident, families and professionals on request. A copy of the home’s Statement of Purpose and Service Users Guide is always made 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.V287621.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector went to the home without telling anyone she was going to visit on the afternoon of Thursday 8th June 2006. Over 2 hours was spent visiting the home, which included meeting 3 of the 4 residents. During the visit to the home the Inspector also: • Spoke with the staff on duty • Looked at some residents care plan records. • Looked around the home. To help the Inspector to write this report the home were asked to provide information, which was given to the Commission on 23rd June 2006. Also the report has taken into account other information, which the Commission knew about the home. There were some important things the Inspector wanted to find out about the care given by the home. These were: • • • • How the health needs of residents were being met. How the personal care needs of residents were met. How the staff helped to kept residents safe and promoted community involvement. How the home respected the resident’s rights, diversity and identity. The term of address preferred by the users of the service has been confirmed as “residents”. If you want to get a full picture of what it is like to stay at Spennithorne Road you might like to read the last report as well. You can find the address or website details on the page 2 where you can obtain the report. What the service does well: • • These are some of the good things that the home does well. The staff team were trained in meeting the health needs of residents. This showed that the staff team were sufficiently skilled to meet the health needs of residents, which in turn meant the residents health was promoted. Residents were supported by the staff to go on holiday at least once a year. Furthermore, residents’ were supported by the staff team to do a range of community activities. This included going shopping, swimming and attending sensory centres. This meant residents were involved in their community and their diverse needs being met. DS0000064119.V287621.R01.S.doc Version 5.1 Page 6 • 10 Spennithorne Road • The residents were seen to be treated as individuals and the staff team provided care that reflected the residents’ rights and preserved their dignity and privacy. This meant that the staff team understood the importance of respecting and seeing the house as the residents’ home. The staffing levels were maintained at a level that reflected the complex needs of the residents, which met their care needs. This meant that the welfare of residents within the home could be adequately met. • What has improved since the last inspection? • The home had improved the monitoring of the residents’ care plans. This meant the staff team were more informed about the updated needs of residents. The access to the entrance of the house had improved. This meant that staff and residents could access the house easily and more safely. The care of resident’s medication was better. This helped the staff to understand better about what medication was prescribed to a residents and why it was importance in keeping the resident healthy. The home had started to investigate ways in which they could monitor the quality of the service. This included asking stakeholders what they thought about the service. This helped the organisation to make positive improvements within the service, which had been done through a consultative approach. • • • What they could do better: Overall, the home was meeting a number of the National Minimum Standards. However, there were some things that had previously needed to be improved which had not been addressed. In addition, some further things were seen that could be done better to ensure that the safety of residents was not put at risk. • At a previous inspection, concerns over the condition of the bath was raised that related to damaged enamel. Although plans had been set up to replace the bath this work had not been done and residents were still having to use a bath that had been damaged for some time. If the bath is not replaced this could affect the health and safety of residents. The care plans needed to be better organised for easier access to information. This would help staff to be certain that they were following the right care plan to meet the needs of residents. It was important that emergency exits and fire extinguishers were checked. Also the fire evacuation plan needed to consider the differences between day/night, the health of residents and the staffing levels. These DS0000064119.V287621.R01.S.doc Version 5.1 Page 7 • • 10 Spennithorne Road needed to be practiced through fire drills. If these checks, records and practices were completed including keeping a record, this would show that everything was being done to make sure that residents and staff safety was protected. • The staff needed to be confident in supporting and encouraging social interaction and safeguarding residents’ health during meal times. This would reduce the chances of a residents’ health being affected and provide them with social stimulation. All staff needed to be helped to achieve their either a NVQ award or equivalent qualification in care. This will ensure they have the skills that in turn will help them to keep residents safe and well cared for. • 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. 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 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.V287621.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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: The home had a static resident group, which had not changed for several years. Reviews of residents care was taking place. This included updating the residents’ care assessments/plans as changes in their needs were identified. 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs were recorded in a care plan that was individual to the specific resident. However, these were not in a format, which allowed updated information to be easily accessed. This had the potential to compromise care practices within the home. EVIDENCE: The residents all had complex health and physical needs, which limited their ability to make certain decisions about their lives. However, the staff consulted with residents throughout carrying out all aspects of care, which was acknowledged by residents through facial and body gestures. The care planning records of two residents were examined. The plans had risk assessments, including manual handling assessments and various risk profiles/assessments that related to residents’ daily living, health and welfare. The home was continuing to move their recording systems towards a more person centred approach through the use of essential life style plans. Support of pictorial aids further strengthened the resident’s involvement. A health plan was the main source of information, which covered most areas of care. This 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 Page 11 included communication, how to keep the resident healthy, and personal and emotional care. The record was set out by establishing needs through set questions, which were focused on the views of the resident. For example “ How I communicate with others”. However, despite this good practice the detail within the plan was sometimes limited in the detail and instead just had a tick. For example, under emotional needs, nothing had been added to the section for additional comments. Sometimes the information about the resident’s needs would slightly vary through the care plan and linked assessments. This included information about a resident’s drinking and eating. One assessment stated the staff team were to sit with a resident while they were eating and others made no mention of this or of the risks such as choking and the need to be supervised. The risk assessments supported the care plan although again varied on instructions. 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15,16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All residents were supported to maintain positive family links and were positively helped to access their local community. Also, their dietary needs were recorded and staff practices ensured residents’ rights and privacy was respected. These all meant that lifestyles were individually respected. However, these good practices were potentially compromised by the limited recognition of the required safeguard to maintain good health, promote sociable mealtimes and meeting the diverse, cultural and religious needs of individual residents. EVIDENCE: The residents were supported to maintain positive links with families. This included staff arranging holidays where family could also be involved. The dietary preferences/needs of residents were selected by them wherever possible. To promote as much choice as possible the care plans held information about meals known to be liked by the resident. Ways to determine dislike were based on the resident’s reaction to the meal. For example, if the resident refused a meal this was considered an indication the resident dislikes 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 Page 13 some part of the meal served and an alternative meal would be offered. During the site visit lunch was being served for two of the residents. One resident required support of a staff to eat their meal. This was seen to be completed at a pace, which was controlled by the resident and done sensitively. A second resident was slightly more independent and to some degree could self assist. However, they needed prompting on using the correct cutlery. Throughout the meal periodic coughing was observed. The staff member supporting another resident was checking the resident remained well, although this meant they had to stop assisting the other resident to do this. On examining the resident’s dietary needs in their care plan it indicated that a staff member should sit with the resident and supervise their eating due to high risk of choking. Yet other than for a brief period this was not completed. The interaction between the resident and staff was observed as very limited and no attempt was made to make the mealtime a more sociable occasion. However, the care plan recorded the type of cutlery and food consistency that was required to ensure the resident’s health was safeguarded and this was observed to be matched in the presentation of the meal served. On asking the staff about social activities they confirmed that activities took place but explained that community based activities could only happen when staffing levels were increased. This was due to the one to one needs of residents in the community as well as the need to ensure the home was staffed with a minimum of two staff. Examples, of activities included residents helping with the weekly shopping and going to sensory and hydrotherapy sessions. From talking with the staff on duty they were aware of the diverse needs of residents in the sense of meeting their cultural and religious needs. Staff explained that one resident received Holy Communion. However, this was not found to be detailed in the resident’s care plan. Furthermore, very limited information was recorded about respecting and meeting the diverse needs of residents. 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Residents’ overall health needs were being met including receiving access to health services. However, a potential weaknesses in the recording details sometimes restricted staff in having all the information they needed to be fully aware of the degree of support/care and aids the resident required to remain healthy. EVIDENCE: The medication charts were examined and provided a good audit trail. Since a previous inspection improvements in recording details about “as and when required medication” (PRN) such as Paracetamol, had been made. On examining the stock levels, it was noted that some of the stock was stored in a cupboard, which for the majority of staff required them to access by having to climb a ladder to reach. Some bottles were stocked on top of each other and on opening the cupboard there was a potential risk that a glass bottle could fall to the floor. It was recommended that the home investigated an alternative lockable cupboard for holding the medication stock. All residents had included in their care plan a health action plan and a personal health record, which carried good information. Furthermore, residents also had included in their records various assessments and reports by health 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 Page 15 professionals which informed the plans. The records all indicated that health screening was positively encouraged and specific health needs were identified in risk profiles/assessments. The only shortfall noticed in the records was the variations in information, which has already been highlighted in this report. Also, the personal health plan was noted not to be dated to indicate when the initial assessment was completed. Other considerations, which were recommended for improvement, were the degree of detail provided. For example under the section for continence, the only information found was a tick to indicate a resident had a problem. A section to record more specific needs was found blank. To demonstrate a resident’s needs were met some level of information should be recorded. When personal care of a resident was required this was completed with staff seeking the residents approval. Whenever the staff member was entering a resident’s bedroom they were observed to be knocking before entering the room. 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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. The families were the main advocates of residents in getting their views and concerns addressed. Furthermore, policies, procedures and training programmes were in place, which the staff were required to attend and adhere to. This ensured that resident’s were safeguarded from all forms of abuse. EVIDENCE: The staff team on duty were asked about their awareness about the protection of residents from abuse and whether they had received necessary training. All indicated receiving training and could demonstrate a general awareness of the way in which residents should be protected from the different forms of abuse. The home had not received any complaints about the service between the last inspection and this site visit. Procedures for residents and their families to make complaints were in place. 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were able to accommodate their possessions, pursue their chosen interests/activities and were offered sufficient privacy. Furthermore, the premises were being kept in a general good state of cleanliness, which protected the residents’ health. However, these areas of good practice were weakened by a failure to address in an adequate timescale the repair to the bathing facilities that had the potential to compromise the residents’ health. EVIDENCE: The staff confirmed that residents with the support of their keyworkers were encouraged to personalise their bedrooms and to have as many things possible which gave them pleasure. This included having important possessions. E.g. photographs of families and religious symbols. Interests such as watching DVD’s and having other entertainment systems in residents’ bedrooms were also encouraged. Part of the keyworkers roles and responsibilities was to ensure the residents all had the things they needed to pursue chosen interests. A partial tour of the premises was completed, including the living area, kitchen and dining area. All areas seen were clean. It had been previously found that 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 Page 18 the space within the home was becoming increasingly restricted due to the use of essential specialised equipment and medical supplies to meet residents’ health needs. Risk assessments around the health needs of the resident and their environment were found. However, on observing care being provided to residents it was noted that furniture required moving to allow safe access. Two requirements from the home’s previous inspection were followed up. Firstly, the incline at the front of the house, which had required assessment to ensure that it did not compromise the health and safety of the staff team when they were assisting residents, had been addressed with a new access ramp. The second requirement related to the condition of the bath that had damaged enamel. The staff said that a decision had been made to replace the bath, which should have happened. However, for reasons unknown to staff this had not occurred and meant they were still having to use the existing rusty bath. To ensure the residents’ safety and health is not compromised a new bath should be installed at the earliest opportunity. 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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. There were good practices in staff training and levels, which reflected the needs of the residents. This meant that there were adequate staff to make sure residents are well cared for and their welfare protected. EVIDENCE: Three staff members were on duty to care for four residents. The staff were able to confirm receiving training in aspects of the residents’ needs including Gastrostomy Care, Person Centred Planning, First Aid and Manual Handling. Also through information provided by the home other training provided in the last 6 months have included Food Hygiene, Rectal Diazepam, Physical Intervention and Communication. However, a weakness identified about training provided to staff, was the numbers that had achieved their NVQ award, which had been confirmed in information provided to the Commission to be 30 . The home needed to improve this level. All staff spoken with could confirm receiving regular supervision from their line manager and that staff meetings were held. Staff files could not be accessed due to the manager not being on duty at the time of the site visit. From information received by the organisation it was confirmed CRB checks had been completed for all staff. 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The organisation made positive improvements within the service by consulting with families. However, the health and safety was less positive and meant that residents safety could be compromised. EVIDENCE: The home had started to investigate ways in which they could monitor the quality of the service including asking stakeholders what they thought of the service. This was found to be helping the organisation to make positive improvements within the service, which had been done through a consultative approach. From examining the fire records and interviewing staff it was identified that some parts of fire safety were not been adequately maintained. Areas of checking the emergency exits (means of escape) and fire extinguishers were not being kept up to date. The fire evacuation plan did not consider the dependency of residents, staffing levels and changes in needs of the residents between day and night sufficiently. Furthermore, the records indicated the last 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 Page 21 practiced drill at the home was in January 2005. The staff interviewed could not confirm completing any drill since their commencement of their employment at the home, although all stated they were told about fire evacuation procedures. If these checks, records and practices were completed including keeping a record then this would show that everything was being done to make sure that residents and staffs’ safety is protected. The manager was absent from the service at the time this inspection was being completed. The assistant manager was overseeing the service during the period. 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 Page 22 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 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 3 25 3 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 YA6 Regulation 15 Requirement The care plan must contain information that ensures the health and welfare of residents is met at all times. This includes ensuring its’ kept under review and that changes in care needs are revised within the plan and assessment so that a accurate up to date plan can be followed by staff at all times. The manager must in relation to the conduct of the home encourage and assist the staff to maintain good personal and professional relationships with residents by ensuring the staff are confident in their roles and responsibilities and interact with residents and meet their health needs during mealtimes. The damaged bath enamel must be repaired or the bath replaced. (Not met in previous timescales set of 30/09/05 and 15/01/06) The home must make sure the fire safety procedures/routines within the home does protect the welfare of residents and staff. This includes: • Carrying out regular fire safety visual checks/tests for the means of escape, DS0000064119.V287621.R01.S.doc Timescale for action 31/08/06 2 YA17 12 31/07/06 3. YA27 23 01/07/06 4. YA42 23 31/08/06 10 Spennithorne Road Version 5.1 Page 24 • • the fire alarm system and fire fighting equipment. This must include keeping a record of these tests. Carrying out regular fire drills including maintaining a record of the type of drill, time and response. To review the evacuation plan to ensure it reflects the different dependency of residents and the variations between the day and night. This must be addressed with staff through fire training. 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 Refer to Standard YA13 YA20 YA32 Good Practice Recommendations It is recommended that more detailed recordings about how the staff support residents’ diverse needs are made. It is recommended that a more suitable stock cupboard is found for holding stock medication. The provider should assist all staff to achieve their NVQ level in Care Award or equivalent qualification. 10 Spennithorne Road DS0000064119.V287621.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 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.V287621.R01.S.doc Version 5.1 Page 26 - 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!