Inspection on 07/06/07 for 11 Bacup Street

This inspection was carried out on 7th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

11 Bacup Street 23/11/05

11 Bacup Street 31/05/05

11 Bacup Street 14/12/04

11 Bacup Street 10/08/04

11 Bacup Street 08/03/04

11 Bacup Street 21/10/03

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 11 Bacup Street 11 Bacup Street Moston Manchester M40 9HF Lead Inspector Steve O’Connor Unannounced Inspection 7th June 2007 11.00 11 Bacup Street DS0000021701.V334658.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 11 Bacup Street DS0000021701.V334658.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. 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 11 Bacup Street Address 11 Bacup Street Moston Manchester M40 9HF 0161 681 9455 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) North West Community Services (GM) Limited Sharon Louise Dixon Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (1) of places 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 3 service users with learning disabilities who may have additional physical disabilities may be accommodated. Within the maximum of the three service users one named service user is over 65 years of age. Should this service user leave the category will revert to learning disability (LD) as in condition (1) above. 23rd November 2005 Date of last inspection Brief Description of the Service: 11 Bacup Street is a residential care home providing 24-hour care and accommodation for 3 persons with learning disabilities who may also have additional disabilities. The Manchester Methodist Housing Association owns the building. The North West Community Services, contracted by Manchester City Council, provide the day-to-day and managerial support. The home is situated in the Moston area of North Manchester and is close to local amenities and transport routes. The home is a purpose built bungalow sited on a residential street. All bedrooms are single occupancy. Communal and kitchen areas are large enough to allow a person with high mobility needs access to all these areas. At the rear of the house is a well-maintained garden. 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the last key inspection report in November 2005. This included the Annual Quality Assurance Assessment (AQAA) completed by the home. The unannounced key inspection site visit took place on the 07 June 2007. During the inspection, time was spent observing how staff work with people who live at the home, talking to the manager and staff on duty and examining people’s files and other relevant documentation. Since the last key inspection report the CSCI had not received any complaints about the home. The home had met the recommendations identified at the last inspection. What the service does well: The home has a clear way of taking referrals that means that they make sure they receive as much information about the person as possible to help them make the right decision as to whether to offer a place at the home. For the most recent person to come and live at the home, this involved meetings with the person, with relevant people and with social and healthcare. The Government’s White Paper on the direction of learning disability services highlights the importance of ‘Person Centred Planning’ (PCP) as the basis on which services should be based and develop. The home has worked very hard to introduce PCP into the way that they work with people to find out important information about the help that they need and build a more personal picture of the whole person rather than just concentrate on problems, needs or what the service thinks is important. The home have worked with people and relevant others to develop individual care plans that can be read like the person is telling you a story about their life, the help they do and do not need and how the home and its staff can help them achieve the goals that are important to them. The home works closely with people to try to find out what social and leisure activities and routines that they enjoy and want to take part in. The home has got to know people and understand the way that they communicate and express their feelings and to make choices. Staff were encouraged by the manager to be imaginative in their thinking about how to support people’s goals and the activities they participate in that 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 6 are valued and meaningful to them. People have been supported to access public transport, local social clubs and facilities, local football matches, cinemas and local attractions. Another important area that is needed when supporting people with little verbal speech is to be able to understand what they are saying through their body language, behaviour and emotions. To understand what people are saying means that they can be offered greater choice, make decisions and so have greater control over their lives. The home has developed detailed guidance in the way that people communicate and this information is used to find out people’s reactions to situations and new activities to allow them to express themselves and be understood. Another area that the home does well is in identifying and supporting people to stay healthy. There is a good understanding of each person’s health needs and the home works closely with healthcare providers such as G.P.s, district nurses, occupational and speech and language therapist. The home has shown that it has a good Induction and Training programme for its staff so that they have developed the necessary skills to support people. The training also focuses on the specific needs of the people they support. If a person requires support in an area such as nutrition and feeding, then the home will provide that training. The staff have worked together as a consistent team and have shown that they have developed a good understanding of peoples’ needs and have to skills and values to provide the support and encouragement needed. Providing people with a nutritious diet is essential in maintaining people’s health. The home has spent time making sure they understand what people like and dislike and provide a choice of fresh cooked meals. Some people need extra help to keep healthy and the home has worked with specialist health services, like speech and language therapists, to make sure that people get the right support and meals they need. What has improved since the last inspection? What they could do better: 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 7 The inspection report has raised a few recommendations for the home to consider. These mostly involve systems for recording evidence of the work they undertake. 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. 11 Bacup Street DS0000021701.V334658.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 11 Bacup Street DS0000021701.V334658.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. Information that the home needs to make a decision as to whether they can meet a prospective person needs and offer them a place at the home was gained. EVIDENCE: Since the previous inspection report one new person has come to live at the home. This person was already being supported by the main organisation (North West Community Services) in another service. Therefore a range of information and assessment materials was readily available for making a decision as to whether the home could meet the person’s needs. In addition the purchasing authority had provided their own care management assessment and further assessments and support guidance had been provided by healthcare providers already involved in this person’s support and care. An in-house assessment was also carried out by the manager of the home and records were maintained of the all the work carried out involving the person’s move to the home. 11 Bacup Street DS0000021701.V334658.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 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are supported so they are able to have choices and make decisions about their own lives in a safe and supportive environment. EVIDENCE: The home had developed a ‘Personal Recording System’ based on the principals and values of ‘Person Centred Planning’ (PCP). This system places the person at the centre of the process and looks at what is important for that person and how they want to be supported and helped. From the assessment information and working with the person the home develops a detailed and person focused care plan. This plan reads as if the person themselves was explaining about their life and history and what help they needed in certain areas. It included their interests and likes and dislikes, their health and other information important to them. It also sets out clearly 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 11 the support and help that people needed to live the life they wanted. The plan then describes the person’s personal goals and what they want to achieve. The review process had been developed to find out if people’s goals had been met and whether changes to the support offered needed to be changed. People’s care plans were reviewed by the staff team on a monthly basis and more formally by the home every 6 months. In addition, the care management review process meant that the service people received was reviewed by the purchasing authority on an annual basis. The home places a high emphasis on understanding the way that people communicate to help them make decisions and choices about their life. Evidence was seen that people’s care plans contained detailed descriptions on the way that they, especially those with little verbal communication, communicate and express themselves. A system for assessing risk and hazards that people may face was being used to develop ways of supporting people to reduce those hazards. Evidence was seen of new risk assessments that responded to changes not only in peoples’ behaviour and support needs but also through changes in legislation and good practice guidance. 11 Bacup Street DS0000021701.V334658.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 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at the home and relevant others have been listened to so as to understand what people want and need to provide a lifestyle based on their wishes and preferences. EVIDENCE: People’s individual care plans clearly showed that the home had spent time to find out about the persons’ interests, likes, dislikes and the type of social, leisure and community based activities that they enjoyed. People are supported to access a large range of activities both within the home and in the local community. Each person has an activities programme based on what they enjoy doing. This programme was very flexible and could change depending on what the person wanted. A lot of emphasis is placed on supporting people to be a part of their own community, to use public transport 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 13 systems and are well known in local clubs and other social venues. A record of the social and leisure activities that people participated in was maintained. The home’s staffing structure and roster was adaptable to ensure that sufficient staff were available at the time when people needed the support to access the community during the times they wanted to. Additional staff were used in a flexible way to support people in the evening for social and leisure events. Due to the way that staffing support is arranged and the wealth of information known about the needs of people means that each person can determine, in their own way, their daily routines. Where people have family they are encouraged and supported to maintain contact and stay involved in people’s lives. Visitors are welcome at any reasonable time and can spend time with people in either the communal or private areas. Through the care planning process the home has identified what meals and foods people like and dislike. They have undertaken appropriate nutritional assessments to identify people’s dietary needs and support and continue to work with specialist health providers to develop clear support guidelines. A good store of fresh and frozen foods was maintained and people are offered a choice of meals based on likes and dislikes. 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported and encouraged to maintain their personal and healthcare in the way the person wishes. EVIDENCE: People’s personal care needs had been fully identified through the PCP care planning. The plan contained clear instructions on how the person wanted to be supported and helped in their personal care. People’s mobility needs had been assessed and were being supported with the use of correct practice and equipment. Moving and Handling assessments were current and updated as people’s needs changed. Each person had their own ‘Health Action Plan’ that set out clearly their health needs, support and the health agencies involved in that support. Clear evidence was found of when people accessed healthcare providers and the outcome of that input. If peoples’ healthcare needs changed referrals were made to the relevant health provider and the home works closely to develop new practice and guidance. 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 15 The home had a clear medication policy and procedure for the administration of medication. All staff responsible for administering medication had received training and had their competence assessed. Information about the prescribed medication was available for staff to reference when required. For people who were prescribed with medication ‘as required’ (PRN) the home had developed clear guidelines for administering that included the triggers for when to administer. The medication system was being audited and monitored on an ongoing basis by the staff and the manager with all deliveries and returns recorded and signed for. Staff were signing the medication administration record (MAR) sheets for a prescribed medication when they did not need to and the prescribing guidance for administering this medication was not very clear. It was also recommended that a record of all thickeners used be maintained. 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Policies, procedures and practices are implemented to try to make sure that people are kept safe and protected from harm. EVIDENCE: The Complaint Policy and procedure contained clear guidance including the stages and timescales of the process. The policy covered all of the North West Community Services. The home provides a complaints leaflet explaining the complaints procedure to make it clear that people and their representatives can contact the CSCI at any time about their worries and concerns. The home had updated the leaflet with the CSCI new contact details. At the time of inspection the service had not received any formal complaints. The home had adopted local authority Multi-Agency Adult Protection Procedures and its Adult Protection Policy was clear and related directly to the ‘No secrets’ guidance. The manager was well aware of the procedures to take in response to an incident or allegation of abuse. In-house adult protection training had been provided for its staff and further refresher training was ongoing. The home had a clear ‘Whistleblowing’ Policy and evidence showed that this policy was made available to the staff during their induction training. The Physical intervention Policy was found to have a clear procedure and guidance. 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 17 There was a system for reporting incidents and concerns that affect people living at the home. Examples of these reports were seen and found to be clear and detailed. People were supported to manage their personal finances. Financial records were checked and found to be accurate and in line with the homes own policy and procedures. There was a clear monitoring and audit check of finances on a regular basis. The Policy relating to supporting people to manage their finances had been updated to include reference to the use and security of cash cards and PIN numbers and included reference to the implications of the Mental capacity Act 2005 in relation to making decisions about peoples’ finances. 11 Bacup Street DS0000021701.V334658.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 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are provided with a safe and homely environment that meets their needs and provides a positive environment for them to live. EVIDENCE: The home provides a clean and homely environment for people living at the home. Furnishings and decoration are all in keeping with a domestic setting and the layout of the building supports people’s mobility needs and the choice of having private and communal space. People’s bedrooms are decorated and furnished according to their own tastes and contain a range of personal decorations and mementos. The manager placed a lot of emphasis on the importance of people having a high quality standard of decoration and furnishings. They were in negotiation 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 19 with the owners of the building for further redecoration and control of a refurbishment budget as there were a few areas that were showing signs of wear and tear such as the kitchen where tiles had fallen from the wall and not been replaced, the kitchen units were slightly damaged in a few places and the extractor fan above the cooker did not work. It is recommended that the kitchen furniture and facilities be brought up to the standard of the rest of the home. That tiles are repaired/replaced, any damaged units are repaired/replaced and that all equipment works correctly. The manager stated that all staff were aware of safe working practices for infection control and evidence was seen that staff had attended health and safety training. The manager was in the process of updating the information on good working practices through recent infection control guidance issued by the National Health Service. 11 Bacup Street DS0000021701.V334658.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, 34 and 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The staff team have the experience, skills and values required to support people’s needs and goals in the way that they wish. EVIDENCE: The staff team consisted of the manager with five full-time and 2 part-time support staff and one on maternity leave. During the day there are three members of staff on duty up to 4:00pm to provide the support people need. This allows all the people living at the home to have 1:1 support. The manager also stated that they would alter the rota to reflect the need to support people in evening social and leisure activities. The majority of the staff team had been together for over 18 months and had developed very positive relationships with the people they support. Evidence was seen how staff worked in a very positive and respectful way with people and included them in all they were doing rather than interacting with themselves. Staff had regular team meetings to share ideas and to discuss the support they provided people. The home also adopted a keyworker system 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 21 where named members of staff take on a specific role in getting to know and support people. Of the seven staff members 2 had achieved the NVQ Level 3 with 3 members of staff waiting for a final grading, one due to start the course and one member of staff already undertaking training to become a qualified nurse. Identification documents required under Schedule 2 of the Care Home Regulations 2001 had been sought and gained for all the staff team. It was also confirmed that CRB disclosure certificates were gained for all of the staff. The organisation (NWCS) had a CRB panel that would discuss any issues of known convictions arising from the CRB check and whether this had an impact on employing a prospective staff member. The General Social Care Council Code of Conduct had been issued to all the staff team. The staff team have access to a yearly training programme of events provided by the main organisation (NWCS). If it was felt appropriate training events can be accessed from other providers or be given by the manager. The home had developed a training plan that was based on each persons needs and the skills needed to meet those needs. The manager stated that the plan would be updated as peoples’ needs changed and did highlight some areas of change in a person’s health and the need for specific training in that area. This would be discussed with the NWCS training department and events would be arranged. Each new member of staff goes through an Induction Programme. This has been reviewed and updated to ensure that it is in line with the national Skills for Care Induction Modules. The new programme involves the staff having to evidence through written exercises and by being observed that they are competent in each of the Induction Modules. Each member of the staff team had a training log that set out the training they had undertaken. Training needs would be discussed during staff supervision and booked through the training department. Evidence was seen of training events that staff had been booked onto including first aid and epilepsy training. It is recommended that the home develop a system for assessing and evidencing the competence of staff in their understanding and implementation of skills and knowledge developed through all training events that they participate in. The manager and training manager were aware of the importance of staff having access to refresher training to make sure that their skills and 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 22 knowledge was up-to-date. Areas such as moving and handling and food hygiene were updated on a regular basis. It is recommended that the home base the need for staff refresher training to be based on the needs and vulnerability of the people living at the home. 11 Bacup Street DS0000021701.V334658.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management and operational systems were in place to meet peoples’ needs and to ensure that they are safe. EVIDENCE: The manager had been in post since 2002 and had achieved the Registered Managers Award in 2003. In addition the manager was a qualified moving and handling assessor and a managing violence and aggression trainer. To ensure that the manager maintains her knowledge she has her own training and development plan. The manager described her management style as ‘hands on’ and maintained her interaction with people and the staff team. She has direct responsibility for the implementation of policies and procedures and maintaining the standards 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 24 of working practices within the home. Since becoming manager of the home they have raised the standards of the service provided to people. The main organisation (NWCS) undertakes monthly inspections of the home to look at issues such as people’s care, care plans, files and records. They will also look at issues of maintenance and the environment, medication and finances. Any outstanding issues or concerns from the inspection are raised with the manager and an action plan agreed, if required. The manager also undertook regular and ongoing environmental checks of the building to make sure it is safe. The manager stated that the purchasing authority undertook a contract monitoring exercise every three months but this did not involve the people who lived at the home. The manager stated that questionnaires asking for the views of people such as relatives, care managers, healthcare providers and GPs were sent out. However, they acknowledged that they received very few completed forms and so found it difficult to get the views of other agencies in terms of the quality of the service they provide to people living at the home. The manager acknowledged that due to communication difficulties the people they support would find it very difficult to be able to express their views of the home directly. Their views were gained on a day-to-day basis through staff offering them choices and options to have control over their daily lives. It is recommended that the home develop a system of quality assurance that links the practice and values of PCP to look at the overall quality of the service. Evidence was provided, in the Annual Quality Assurance Assessment, that all the required health and safety checks and equipment servicing had been completed and was up to date. Environmental risk assessments and health and safety checks had been reviewed and updated if required. The fire log showed ongoing and regular checks of all equipment and fire drills. The fire risk assessment had been updated and some changes made in its procedures and provision of equipment to try to ensure that the risks and hazards from a fire were minimised and that staff were all aware of their role. 11 Bacup Street DS0000021701.V334658.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 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 4 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 2 X 4 X 3 X X 4 X 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations It is recommended that the MAR sheets must accurately reflect the actual administering of medication. It was recommended that a record of all thickeners given to people be maintained. 2 YA24 It is recommended that the kitchen furniture and facilities be brought up to the standard of the rest of the home. That tiles are repaired/replaced, any damaged units are repaired/replaced and that all equipment works correctly. It is recommended that the home develop a system for assessing and evidencing the competence of staff in their understanding and implementation of skills and knowledge developed through all training events that they participate in. 3 YA35 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 27 It is recommended that the home base the need for staff refresher training to be based on the needs and vulnerability of the people living at the home. 4 YA39 It is recommended that the home develop a system of quality assurance that links the practice and values of PCP to look at the overall quality of the service. 11 Bacup Street DS0000021701.V334658.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North West Regional Office 11th Floor West Point 501 Chester Road Old Trafford 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 11 Bacup Street DS0000021701.V334658.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!