Inspection on 17/09/08 for 10a Coates Lane

This inspection was carried out on 17th September 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10a Coates Lane 03/10/07

10a Coates Lane 05/06/06

10a Coates Lane 28/11/05

10a Coates Lane 03/06/05

10a Coates Lane 10/01/05

10a Coates Lane 29/04/04

Similar services:

Alfred House Residential Care Home

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Fernhaven

Thames House

Creative Support

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 04/12/2008.

CARE HOME ADULTS 18-65 10a Coates Lane Whitehaven Cumbria CA28 7BZ Lead Inspector Nancy Saich Unannounced Inspection 17th September 2008 11:00 10a Coates Lane DS0000022544.V371699.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 10a Coates Lane DS0000022544.V371699.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. 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 10a Coates Lane Address Whitehaven Cumbria CA28 7BZ 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) 01946 691336 karen.russell@turning-point.co.uk Turning Point Mrs K E Russell-Haines Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 9 service users to include: up to 9 service users in the category of MD (Mental disorder, excluding learning disability or dementia under 65 years of age) 1 named service user in the category of MD(E) (Mental disorder over 65 years of age) may be accommodated within the overall number of registered places. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 3rd October 2007 2. Date of last inspection Brief Description of the Service: 10a Coates Lane is a Georgian house situated in the centre of Whitehaven. It is home to nine people who have long-term difficulties with their mental health. The home is operated by Turning Point who run residential homes and other services throughout the country. Karen Russell- Haines manages the home on their behalf. The home is on two floors and is not suitable for people who have problems with their mobility. Information about the home can be obtained from the manager at the above address or from Turning Point’s website. Charges range from £337 to £1057 per week 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for this service is one star. This means that people who use this service experience adequate quality outcomes. This was the main or key inspection for the year. The lead inspector Nancy Saich asked the manager to fill out a form called the Annual Quality Assurance Audit (the AQAA). This asks for details of what has improved in the home since the last inspection and for the plans for the coming year. This was completed promptly with plenty of detail. We then visited the home briefly and met with the residents’ representative. She kindly agreed to give out surveys to everyone who lives in the home and to give them surveys for their relatives, friends and for people like social workers and doctors. We sent staff surveys to the home. We had a good response to these surveys and we quote from them in the report. The responses were fairly positive and gave us a good picture of what its like to live and work in the home. We made an unannounced visit where we met with all of the residents and the staff on duty. We walked around the building. We also looked and files and documents that backed up what was said and what was seen. What the service does well: Here as some of the things people said about the service: • • • • The staff are very helpful I know how to make a complaint and if I were unhappy I would speak to the manager straight away They do Christmas and birthday parties really well. The home lets my mother have a free rein to do what she wants. And from a member of staff: • The service treats all users as individuals and this creates a good working relationship for both service users and staff. As their care plans are always up-to-date it is so easy to keep up-to-date with things. A health care professional told us he felt the staff team: 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 6 • “ Keep a good eye on everyones physical health as well as their mental health problems.” This service is good at only taking on new people who they know will fit in with the existing residents and whom they are sure they can care for. We saw good care plans that helped people make the most of their lives and we also saw that for most of the time people were supported in taking suitable risks. We saw that individual residents were given a lot of say about how decisions were made in the service and that they had an influence over decision making in the company. We spoke to a number of residents and had other evidence to show that people enjoyed hobbies and leisure activities, were involved with what was happening in the local community and had visits from family and friends. Several people had gone on holiday both in Britain and abroad. Residents told us that they had certain responsibilities in the house and that staff respected their rights. Residents told us that they were happy with the way the staff group helped them with their personal care. We were pleased to see that people were asked their preferences and some people specifically asked for help from a person of the same gender. There was also a lot of evidence to show that people who live in this service are supported in getting good physical and mental health care. We judged that people are given suitable medication and that the service looks after medicines properly. People who live in the service told us they have a residents’ representative who goes to staff meetings and to residents groups run by Turning Point. Everyone said that his or her concerns would be taken forward. Staff and residents were aware of the nature of abusive treatment. Everyone spoken to said there was nothing of this kind in the home. Residents felt confident that they would be able to disclose anything like this and the staff team were able to describe how they would manage any safeguarding problems. This service is good at making sure that any new members of staff have the right kind of background and approach that will make them good people to work with residents with mental health needs. The manager makes sure that the right checks are made on each new member of staff. The home has a suitably qualified and experienced manager and several people told us they could go to her for help and support at any time. 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 7 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. 10a Coates Lane DS0000022544.V371699.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 10a Coates Lane DS0000022544.V371699.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. This service will only admit a new person once they are sure they can care for them and that they will fit in with the other people who live in the house. EVIDENCE: There have been no new admissions since the last time we visited but we could see from individual resident’s files that each person had an assessment before they came to live at Coates Lane. There was lots of evidence to show that the admission procedure for this home is very thorough and involves the opinions of residents. The policy encourages people to visit on more than one occasion so that they can make up their mind about the placement. We could also see that this assessment process continued after admission and that the manager was careful to monitor any changes to individual residents. 10a Coates Lane DS0000022544.V371699.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): 6,7,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. This service helps people to get suitable levels of support to help them to be as independent as possible. EVIDENCE: We looked at all of the written care plans in the home and read approximately one third of them in a great deal of depth and spoke to those three people. The residents’ files had lots of information about their lives, their choices and the support they needed. We could see that care planning in this service continues to improve and we were pleased to see that plans continue to be detailed, person centred and suited to the needs of individual. We could also see that every member of staff was being coached in drawing up the plans. We spoke to people who use the service and they were aware of their plan and told us that they were very involved in drawing them up. We look forward to seeing this depth of work continuing and we hope that the new 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 11 plans -- The Wellness Recovery Action Plans (WRAP)-- become a useful tool for helping people to move forward with their lives. Residents told us that they have regular one-to-one sessions with their key worker -who helps them to draw up their care plan. Each person in the home has regular reviews of their mental health care plan (The Care Programme Approach -- CPA) and we read a number of these and found that, in the main, mental health professionals were happy with the way care was delivered in the home. This home has regular service user meetings. The manager works closely with them and they told us that more senior managers from Turning Point also come to the home and are happy to listen to their opinions. Each person has regular care planning meetings and most people also have individual time written into their plans. All these things mean that people are suitably supported in decision-making, participation and risk taking. The home has a resident’s representative who attends staff meetings and also participates in user involvement groups with Turning Point. She assisted us with the survey work for this inspection. We think that this is an example of good practice. Each resident’s file also contained very detailed risk assessments and risk management plans. We judged that these are beginning to help people to develop more confidence in taking control of their lives. There was an issue around risk taking on the day of the visit and this is discussed under Standard 42. 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents in this home are beginning to have a varied and interesting life that helps them rebuild their lives and allows them to experience new things. EVIDENCE: We had evidence to show that the people who live in Coates lane are very much part of the local community of this Cumbrian town. The home is situated near to shops, cafes, restaurants and bars. The residents enjoy going out nearly every day - some on their own, others with staff. There are opportunities for individuals - or for the entire group - to go to local entertainments and clubs. Some residents who are older people enjoy attending clubs specifically for their age group; other people attend classes and activities that are enjoyed by everyone in the community. 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 13 One person told us about her interest in keeping healthy and she has signed up to an evening class where she can learn more about this. On the day of the visit one person was waiting for her family to drop in. Another person spoke about going on holiday with her family and yet another person spoke about the regular contact with a partner. Several people have gone on holidays this summer and were supported by staff to do this. People who live in this service are encouraged to have friendships and relationships with people outside of the home and are given opportunities to do this. Each person in the home has a key to his or her own room and staff are careful not to go into these rooms without permission. We saw that individuals in the home made their own choices about how they spent each day. One person likes to sleep late and stay up late and this is accepted. Residents are encouraged to participate in daily tasks like washing-up, tidying their own rooms and helping to prepare meals. We could see that staff were keen to promote these daily living tasks and we look forward to some of this work becoming integrated with objectives in care planning. We had plenty of evidence from surveys and from discussions with people to show that on a normal day people were happy with the food provided and in the environment where they eat their meals. (There was a problem on the day of the inspection and this is discussed under Standard 42.) We were shown new menus and were impressed with the fact that each week residents sit down together with one member of staff to discuss what they want to eat. We also thought that the themed nights were a good way of introducing people to the food of different cultures. Residents told us that they also enjoyed more old-fashioned meals that reflected their Cumbrian background. We noted that some people had problems with maintaining weight and that some people had problems with things like cholesterol levels. All of this was seen in the care plans but we think that the time is now right for the management to look at more formal nutritional planning for some people and we recommend that there is a new focus on healthy eating in the home. Both residents and staff said that they would be interested in doing this and they felt that it was something that the group could do together. 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use this service are happy with the personal and health care support they receive and tell us that they receive suitable levels of privacy and choice. EVIDENCE: Residents told us that they were happy with the way they were assisted with personal care. There was evidence in care plans to show that this was done in a sensitive way. For instance each person had been asked about their preferences for the gender of the person assisting them. There was also evidence in staff supervision to show that personal care support was given a lot of consideration. Residents told us that they were supported in accessing both physical and mental health care. Residents’ files showed that this was the case, that their medication was reviewed regularly and that they were encouraged and supported in going for routine medical screening. We had other evidence to show that healthcare professionals were happy with the way the service users were supported. 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 15 We checked on the medicines kept on behalf of service users and found them to be in order. Where people were taking drugs for their psychiatric conditions these were monitored by psychiatrists or community psychiatric nurses. The manager told us in the AQAA that she was working towards helping some people to take their own medicines. This was confirmed by one of the service users. There had been an error in one persons medication but this had been spotted very quickly, put right and steps taken to make sure this wouldnt happen again. This showed that their quality checks work well. 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use this service are protected from abuse and their complaints, comments and concerns are listened to and acted upon. EVIDENCE: We spoke to service users about how they would make a complaint. They said that they could do this in residents meetings or could speak directly to the manager. They felt that any concern was taken seriously. They said that the resident representative could discuss any concerns with the full staff group at staff meetings. There had been no major complaints about the service but management had taken a number of suggestions and concerns forward. We also asked service users about how well protected they felt from abuse. People told us that they considered that the staff group treated them well and were aware of any potential harm. We spoke to staff about their role in safeguarding vulnerable adults and they were aware of their responsibilities. We had evidence to show that the manager is able to report any actual or potential harm appropriately. We saw minutes of residents and staff meetings where safeguarding was on the agenda. Staff had received suitable training, there were good policies and procedures in place and there was evidence in individual staff files to show that Adult Protection is taken seriously in this service. 10a Coates Lane DS0000022544.V371699.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 adequate This judgement has been made using available evidence including a visit to this service. The home is not as comfortable as it ought to be for residents due to ongoing refurbishment work and problems with cleanliness. EVIDENCE: 10 a Coates Lane is a Georgian property situated in the centre of Whitehaven. There are restrictions imposed on this building because it is ‘listed’ and this means that improving disabled access has been problematic in the past. The manager is aware that this means that people with a disability may be disadvantaged by the access arrangements. The building has had numerous problems over the years - mainly with the roof and the rendering - and this has led to penetrating dampness in several bedrooms and in the hall. The company has tried to get their landlord to deal with this in the past but repair work has not solved the problem. The landlord - Impact Housing- has now agreed to carry out the necessary major building works to solve this problem. 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 18 Turning Point tell us that the roof of the building is to be made good and all the external render is to be removed and replaced. Once this is done the internal décor will be improved. They also tell us that there will be other improvements to the internal layout that will improve the environment for the service users. These improvements have been delayed by a year for a number of reasons but the building work has now started. We would like Turning Point to continue to update us with the progress of this and when the external work is finished we would like to see details of the measures taken to improve the building. We looked at a number of upstairs bedrooms and could see that the penetrating dampness was still evident. We judged that this had not become worse as some interim repair work had taken place earlier in the year. Residents told us that dehumidifiers had been used and we urge the staff group to continue to use these in damp rooms until the work has been completed. A number of residents continue to sleep in rooms that have been affected by dampness. On the day of the visit the main hall, the sitting room and at least one bedroom were affected by malodours. The smell was one of pervading dampness but we also detected the smell of urine. We were told that carpets were due to be cleaned. Some carpets were in need of being vacuumed and spot cleaned. Several areas were dusty because of the building work and this included the kitchen. We also judged that most of the bedrooms needed to be redecorated. We are aware that the structural work needs to be done first. However the current situation means that the environment is not as pleasant as it ought to be. We discuss these matters further under Standard 42, ‘ Safe Working Practices’. 10a Coates Lane DS0000022544.V371699.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, 33, I had 34, 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service needs to update training for staff and continue to work on individual development plans for staff so that people who live in the home will be cared for in a safe and a suitable way. EVIDENCE: We looked at the recruitment files for the last three new members of staff and we found that their recruitment had been handled well. The manager had made sure that she checked their identity, background, experience and knowledge. Two of the staff were around on the day and they confirmed that their recruitment had been fair and thorough. New staff in this service undergo a very thorough induction programme that helps them get used to the work that they do. Residents said that they felt the staff team had the right kind of qualities to give them support. We could see in staff files and by observation and discussion that this staff team are highly motivated and very aware of the needs of service users. The manager tells us that 66 of the staff team have National Vocational Qualifications at level 2 or above. 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 20 We also checked on staff training and we discovered that people had completed things like food safety training and medication management. We saw that people had gone on different types of training that had been identified in supervision. This company uses a form of staff development called Performance, Development, Progression and Outcomes. This is tied in to the overall quality assurance of the operation. We saw how this was working for individual members of staff and we thought that generally this was effective. We did find some gaps in individual development plans. For example we discovered that some staff need to update their skills, knowledge and competence in manual handling of things and people. Some people have had too little input and others need updates to their original training and checks on their competence. The team does not need to undertake a lot of manual handling of people but we judged that this training is necessary because at any time they may have to manage someones personal care needs by using manual handling techniques. We recommend that people receive updates as soon as possible. On the day of the inspection we could see that staff worked well with the service users and their care needs. However there were a number of examples that showed that these support workers were having difficulty seeing the bigger picture that keeps residential care homes running smoothly and safely. We discuss this further under Standard 42. We want the manager to make sure that all staff understand that they have day-to-day responsibilities that include managing the environment on behalf of service users. We were not sure that all staff were aware of all the responsibilities of their job role and we recommend that management address this. 10a Coates Lane DS0000022544.V371699.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 adequate This judgement has been made using available evidence including a visit to this service. The service needs to make sure that they always attend to the details of the health and safety systems in the home so that residents will be kept safe and well no matter what is happening in the building. EVIDENCE: This service has a suitably qualified, competent and experienced manager. We had evidence to show that she puts service user needs at the centre of everything she does and that she has been working with her user group to help them become more empowered. On the day of the visit the manager was on holiday. We judged that most of her systems continued to function well in her absence but we could see that staff were not really managing the health and safety implications of refurbishing a building with people in residence. 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 22 The home uses a specific quality assurance tool that has been developed for their kind of setting. We receive regular monthly updates showing that senior managers visit the home and we saw on the day that there are regular checks on how things are managed in the home. Service users are asked their opinion and their views are taken into account. However on the day of the visit we discovered that this quality monitoring system was not working as well as it might to ensure the home was operating safely. There were two matters that caused us concern about safe working practices in the home. The first was in relation to the building work that had started two days before. Shortly after the inspection started we went into the kitchen/dining room and found that this room (and the nearby fridges, work surfaces and food preparation areas) were badly affected by dust from the building work outside. We also saw that the workmen were using electrical sockets inside this room. There were three voltage conversion boxes and trailing cables in the dining room. Two people who live in the home were trying to eat their lunch in this environment. Staff had not resolved this potential risk for residents or for themselves. We asked the staff to deal with this straight away. Residents were moved out and the workmen were asked to stop work until the problem of access to electrical points was resolved. This happened very quickly and staff confirmed their actions with senior management. We could not find an up-to-date risk assessment or management plan for this building work. We were contacted by Turning Point management shortly after the inspection and informed that a daily site visit was to be put in place and that they had written a new risk management plan for this building project. We make the requirement that Turning Point continue to risk assess this refurbishment so that residents and staff can be assured of their health, security and safety during this necessary work. We also looked at the fire logbook. We found that the fire risk assessment needed to be updated because of the building work. We saw that residents had taken part in fire drills and instructions but when we asked for records of staff drills and instructions we discovered that these were not up to date. We were concerned about this because we could see that due to the scaffolding around the building, workmen on site and restrictions to exits there was a potential risk in relation to fire prevention, fire management and evacuation. The manager must make sure that all staff and residents know of any changes to fire safety arrangements while building work is in progress. 10a Coates Lane DS0000022544.V371699.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 1 2 3 4 5 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 4 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 2 X X 1 X 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 13 (4) Requirement Timescale for action 30/10/08 2. YA42 23 (4) The registered person must ensure that suitable arrangements are in place to manage the risks associated with the current building work. A risk management plan must be put in place and updated as the building work progresses. The registered person must 30/10/08 ensure that fire instruction and drills take place at regular intervals and that the fire risk assessment and fire management plan are updated regularly in line with the current building work. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA17 Good Practice Recommendations It is recommended that the home look at a system that will assist them in nutritional planning for risk factors associated with low weight, obesity and health problems. DS0000022544.V371699.R01.S.doc Version 5.2 Page 25 10a Coates Lane 2. YA24 3. 4. 5. 6. YA30 YA33 YA35 YA39 It is recommended that Turning Point continue to update the Commission for Social Care Inspection about the progress of the refurbishment project. It is also recommended that a report be compiled once the building work is completed that will give evidence that the refurbishment will be effective against dampness. It is recommended that cleaning regimes be formalised during the refurbishment work so that good safety, health, hygiene and food safety levels are maintained. It is recommended that the manager review her staff development plan so that all members of staff can safely manage the day-to-day running of the home. It is recommended that the manager ensures that every member of the staff team have updates to their manual handling training and also have their competence checked. It is recommended that the manager review the quality systems for checking on health and safety and fire safety to make sure that these always work so that residents are suitably protected. 10a Coates Lane DS0000022544.V371699.R01.S.doc Version 5.2 Page 26 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. 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