CARE HOME ADULTS 18-65
136d Warminster Road 136d Warminster Road Norton Lees Sheffield S8 9PQ Lead Inspector
Ms Shelagh Murphy Key Unannounced Inspection 9th January 2007 09:00 136d Warminster Road DS0000061670.V312406.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 136d Warminster Road DS0000061670.V312406.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. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 136d Warminster Road Address 136d Warminster Road Norton Lees Sheffield S8 9PQ 01142 734990 01142 750940 none 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) Sheffield City Council - Disabilities Services Division Mr Steven Danford Care Home 2 Category(ies) of Learning disability (2) registration, with number of places 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd March 2006 Brief Description of the Service: Warminster Road is a care home providing short-term care for up to two adults with learning disabilities. It is in a residential area of Sheffield with good access to public services and amenities (e.g. bus services, shops, libraries and pubs). The home is a two-storey house. Accommodation consists of a lounge/diner and kitchen area on the ground floor. On the second floor there are two bedrooms. There are sufficient toilet and bathing facilities. The cost of the service varies dependent upon the age of the service user, the fees at the time of the inspection were £10.30 per day for people under 25 years, £12.00 per day for people aged 25-59 years and £16.59 for people aged 60-65 years. These fees included all meals. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Shelagh Murphy and Ian Hall carried out this unannounced inspection on 9th January 2007 from 09.00 to 2:40 pm and Shelagh Murphy made a second visit to conclude the inspection and speak to service users on 15th January 2007. Warminster Road Short stay service provides short-term, flexible care for adults with learning disabilities. Three service users were at the home on the second day of the inspection. Two for an overnight stay and one person was visiting the service for a tea visit to try out the service. Opportunity was taken to make a tour of the premises, inspect a sample of records and policies and talk to the service users, managers and staff. One relative was spoken to on the phone to seek their views. What the service does well:
Warminster Road is a care home providing short-term care for up to two adults with learning disabilities. The service was first registered in June 2005 and this was the second inspection since registration. Overall this service offers a high standard of care and support to numerous people who use the service and there was evidence of a high standard of satisfaction from people who use the service and their relatives/carers from the number of compliments and Thank you cards sent to the service. One service user said, “I like it here the staff are nice and I’ve got my own room, where I can do my art”. Another person described the staff as “friendly” and as “they help me”. One relative stated that her son was, “really happy” at the service and that she felt he was safe and the service gave her some respite support, which she really needed. The people who use the service are assessed prior to being offered a placement and they are offered the opportunity to go for tea visits to give the service a trial run before staying over night. The manager reported that the service operates at more or less full occupancy for most of the time and has numerous regular people who use the service regularly. The people who use the services have individual care plans and these are reviewed on a six monthly basis. The service users and their relatives can attend reviews if they so wish. One of the people who used the service told the inspector they had regular opportunities to access appropriate activities. During the week people were supported to attend day centres and educational groups within the local community. The staff said that varied activities were organised at the
136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 6 weekend, which included visits to the park, pub lunches and visiting the local shopping centre. Service users were offered and encouraged to eat a healthy diet. The weekly menu was planned in consultation with the people staying at the service, to ensure that all individual needs were catered for. There was a comfortable, informal and relaxed atmosphere in the home. Relationships between the staff and people who used the service were appropriate, warm and informal. All areas within the home were homely, clean, tidy and well maintained. The staff had an excellent knowledge of people who used the services individual needs and said that many of the people stayed at the home on a regular basis, enabling them to gain a good insight of their likes, dislikes, preferred routines and care needs. Minimum staffing levels were being maintained and the manager said that extra staff would be provided where there was an identified need. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of people. Newly recruited staff had completed the services induction training, which will give them a recognised induction into supporting the people who use the service. There appeared to be good relationships between the staff and managers who were described as approachable and supportive. What has improved since the last inspection?
The statement of purpose and service users guide had been reviewed and up dated to ensure that prospective service users and their carers had the information that they needed to make an informed choice about using the service. The home had been redecorated and refurbished since the last inspection and was furnished with high quality fixtures and fittings. It was homely, clean, comfortable and well maintained. People who used the service dependent on their needs had facilities to make tea and coffee provided in their rooms. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 136d Warminster Road DS0000061670.V312406.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 136d Warminster Road DS0000061670.V312406.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area was good. This judgement has been made using available evidence including records, looking at preadmission information, procedures and discussions with service users, their relatives and staff members. The statement of purpose and service user guide had been reviewed. Initially Only two of the four peoples needs assessments were available on the files checked. The other two were found prior to completion of the inspection. They contained appropriate information about the service users care needs, and how these should be met, which ensured that the service was able to meet individual needs. EVIDENCE: The statement of purpose and service user guide had been updated and had the information that prospective residents needed to make an informed choice about using the service. Four peoples needs assessments were checked. Initially information was found to be missing from the two service user files, this was found before the end of the inspection. The files contained details of a full needs assessment; this confirmed that the service could meet the needs of the service user, and provided staff with the information to formulate an individual plan of care. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 10 Discussion with service users confirmed that they had had an active role in choosing to stay at the home. One service user said, “I like it here the staff are nice and I’ve got my own room, where I can do my art”. One relative stated that her son was really happy at the service and that she felt he was safe and the service gave her some respite support. The inspector met a prospective service user who was visiting for tea before making an informed choice about using the service. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 11 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 and 9 Quality in this outcome area was good. This judgement has been made from evidence gathered during the visit to this service. Records were checked. Evidence was also gathered by observing and speaking to the people who use the service, their relatives and the staff. Initially some of the service users care plans and risk assessments did not reflect all of the service users needs in order to ensure they were being supported appropriately by staff. However, after this was brought to the manager’s attention, these documents were completed appropriately before the end of the inspection. People who used the service were observed to be offered the opportunity to make everyday decisions by the staff. EVIDENCE: Four care plans were checked; two of these were up to date and detailed the service users needs and the level of support that staff needed to offer each individual. These care plans had also been reviewed to ensure the service could still meet the needs of the people it supported. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 12 Two other service user plans, which belonged to the most recently, admitted service users did not contain all of the information required by the regulations. This was brought to the assistant manager’s attention and this information was incorporated before the end of the inspection by the service users key worker. Appropriate information including all aspects of service users, personal, social and physical care needs had been included in these plans. One service user showed the inspector their care plan and obviously knew the kind of information it contained, as he was able to explain some of the contents. He also said he had attended care plan reviews. Four service users files were checked; two contained numerous risk assessments for the individuals to be supported in taking risks as part of an independent lifestyle. Two others were limited in that they only incorporated manual handling risk assessments. This was brought to the manager’s attention and then appropriate risk assessments were put in place to protect the people who used the service and the staff working with them. Observations of the interactions between the staff and people who used the service showed that people were empowered to make everyday decisions about their support and other needs. People were offered choices of food and drinks, were offered support to make these and generally given opportunities to decide how to plan their evenings activities. One person described the staff as “friendly” and “they help me”. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area was good. This judgement has been made using available evidence including sampling service user personal files, activity records, inspecting the catering arrangements and discussion with people who used the service and from speaking to the staff team. People who used the service were encouraged to maintain and develop social and independent living skills. They were also offered opportunities to take part in activities within the home and maintain links within the local community. Relationships between the service users and staff were appropriate and friendly and people were supported to develop relationships with their peers and maintain appropriate relationships with their relatives and friends. People were encouraged to eat a healthy and varied diet to meet their individual needs. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 14 EVIDENCE: Staff were observed to facilitate peoples attendance at their chosen educational and community activities whilst staying at Warminster Road. They managed this by supporting people to get ready for the day care transport and ensuring that people had appropriate clothing, medication if appropriate and expenses etc. for the day. Service users described a wide range of activities they had chosen to participate in during their stay; these included ice skating, shopping locally and in the city and visits to the pub for an evening. These activities were recorded within their care plans and files. The manager advised that additional staff are provided should the need arise to ensure service users can undertake activities of their choice. The staff interviewed said that various activities were organised at the weekend, which included visits to the park, pub lunches and visiting the local shopping centre. Through discussions with staff it was evident that people were encouraged and supported in developing relationships with their peers through outings and activities within the home. The service users said the staff helped them to phone their relatives and friends as appropriate. It was observed that there was a very respectful but informal relationship between the staff and people who used the service. People were offered and encouraged to eat a healthy diet. The weekly menu was planned in consultation with the people staying at the home, to ensure that all needs were catered for. The staff had a good knowledge of individual’s preferences. The service users dietary likes and dislikes were known and recorded in their plans. The three people at the home on the day of the inspection each chose a different meal for their tea and were asked if they wanted to participate in its preparation. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. 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 interviewing the assistant manager; talking to people who use the service and a relative. Speaking to and observing staff as they worked and by checking medication and records. The manager and staff were able to demonstrate how most people’s physical and emotional needs were met, through discussions and records. However, some of the care plans checked required more detailed information to ensure that the specific needs of people were recorded. The assistant manager was advised of this and appropriate, information had been included by the end of the inspection. Medication procedures were checked and showed some errors and issues, which needed to be addressed. EVIDENCE: Four care plans were checked, two were excellent, two others did not fully describe the action required by staff to ensure that all aspects of the individual’s social, physical and healthcare needs were met. However, they had been updated by the end of the inspection and were very detailed. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 16 The staff had a good knowledge of most people who used the service and had formed positive, appropriate and warm relationships with people. They needed time to develop similar levels of understanding for people who used the service infrequently or who had just been admitted. Many of the people who used the service stayed at the home on a regular basis, one service user described attending the service as his “holiday” away from home. The staff and manager confirmed that there was sufficient staff to meet the individual needs of people who used the service and staff rotas were checked which confirmed this. The assistant manager confirmed that extra staff would be provided where there was an identified need. Medication procedures and records were checked at the home and some errors in signing for medication were found, this did not fully protect the people who used the service and action was taken by the assistant manager at the time of the inspection to address the issues. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected 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 checking records, interviewing the registered manager; observing staff as they worked and speaking to the people who used the service, staff and a relative. The homes complaints procedure was clear and accessible, ensuring that any complaints made by people who use the service or their relatives/carers would be listened to and action taken to deal with complaints promptly. No complaints had been made about the service but there were numerous compliments logged including thank you cards and letters from service users and relatives/carers. There was an adult protection procedure, which promoted the protection of people. Staff and managers said they had received adult protection training but the records to evidence this were incomplete. EVIDENCE: The complaints procedure was appropriate and included information about how and who to make a complaint to. This gave timescales for how the complaint would be responded to. This ensured that people who used the service and their relatives/carers were aware of how to make a complaint and who would deal with them. It was clear from speaking to the people who used the service that they knew they would be listened to and that complaints were dealt with informally. The staff said the manager would listen to and take appropriate action to deal with any issues. The manager confirmed and records demonstrated that no complaints had been made to the home. There were numerous compliments
136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 18 logged in the files, which demonstrated how highly the service was thought of and was able to meet people’s individual needs. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. The staff and managers said the staff had received adult protection training, enabling them to identify and report any allegations or incidents of abuse. The staff interviewed knew how to report allegations of abuse and the signs and symptoms to be aware of, however, the staff training records checked did not clearly identify when and if all of the staff had completed adult protection training in the last two years. This will need to be checked and clear up to date records need to be kept to evidence this in future. The manager confirmed this would be dealt with as a priority. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a tour of the premises, viewing bedrooms, communal areas and kitchen. Checking records including those on maintenance and health and safety. The home was well-maintained, comfortable, odour free, and homely. The bedrooms were comfortable, individually decorated and furnished to meet the needs of a range of people who used the service. Laundry facilities were limited but staff followed procedures to ensure high standards of cleanliness in the kitchen. EVIDENCE: The home is based in a two-storey house. Accommodation is on two floors and consists of a lounge/diner and separate kitchen area on the ground floor. On the second floor there are two bedrooms. There are sufficient toilet and bathing facilities. This service is not suitable for wheelchair users or people with mobility problems, which limit their ability to use stairs. The home had been redecorated since the last inspection. It was homely, comfortable, clean, well presented and equipped with good quality furnishings
136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 20 and fixtures. The lounge/diner had a non-slip wooden floor, contemporary light fittings and new dining table and chairs. There was TV, DVD player and music centre provided for people use. The people who used the service said the home was “lovely” and “I like the bedroom I stay in”. A relative described the home as “homely and really clean and tidy”…and went on to say “the staff look after it”. The bedrooms were individually decorated, clean and each had a television and video. The manager said that a DVD player and tea and coffee making facilities were available, subject to individual risk assessment, in each bedroom. The kitchen was domestic in nature and had been refitted and equipped. There was a domestic washing machine in the kitchen which was only used when food was not being prepared and staff confirmed that appropriate hygiene procedures were followed after soiled washing was placed in the machines. The garden area of the home was level and seating was provided. There were shrubs and plants; this provided a pleasant seating area for people to use when the weather is warm. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 21 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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including interviewing the staff, speaking to the registered manager and by checking training and recruitment records. Staff had received training to enable them to meet the service users needs. A good range of training was available for staff. However, the training records needed to be updated, to ensure the staff received on going and refresher training as required. Appropriate support and guidance was offered to new staff, via an induction enabling them to safely care for service users. The home operated a thorough recruitment policy that promoted the protection of service users. The staff files contained adequate information to ensure the protection of people who used the services. EVIDENCE: It was obvious from observing the staff and service users interactions and from speaking to the staff that they had the qualities and qualifications required to meet the needs of the people who used the service. The Staff were approachable, friendly and confident in the way they approached their roles. Staff spoken to said that they enjoyed working at the home, that they felt well supported and said that the training offered by the service was very
136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 22 comprehensive. Over 85 of the staff team had completed the NVQ2/3 care awards, which is excellent. A thorough staff recruitment policy and procedure was in place. Three staff files were checked and contained a range of information required by the regulations including application forms, two references, declaration of health and qualifications/training, clear CRB checks. The manager confirmed that all staff had received a Criminal Records Bureau Check at the enhanced level to promote the protection of the people who used the services. A comprehensive training and induction programme for staff was in place enabling them to meet the assessed and changing needs of people. Discussions with staff and records checked demonstrated that most staff had received a good range of training that included Moving and Handling, First Aid, Fire Safety and Health and Safety issues. The staff training records checked showed that most but not all staff had received refresher training in areas including adult protection, food hygiene and administration of medication. This was brought to the attention of the management and will need to be up dated and then an accurate training record must be kept in the future. 136d Warminster Road DS0000061670.V312406.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including interviewing the registered manager; observing staff as they work. Rotas, fire safety and other health & safety records were inspected. The staff interviewed described how the managers supported them. They all said that they felt they were well supported by the managers. A quality assurance system to monitor the service was being devised at the time of the inspection. The manager confirmed there was no formal system in place at this time. Overall, the health, safety and welfare of people who used the service was promoted and protected. EVIDENCE: The manager is an experienced manager who had a NVQ level 4 registered managers award, which he acquired in December 2005. He was able to provide leadership and support to his care team, as was the assistant manager.
136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 24 Staff commented that the managers were supportive and approachable. There was no formal quality assurance monitoring system in place for the protection of service users. Feedback had been gained from service users and their carers in the form of, Thank you letters and cards, these were very complimentary and described the care and quality of service that had been provided at Warminster Road. Visits to the home by the responsible person had been carried out, however, these were not on a regular monthly basis and this will need to be addressed to ensure monitoring of the service is continuous. Health and safety risk assessments for people who used the service and the premises were found to be up to date and had been reviewed. Records of the servicing and maintenance of gas, electricity and fire systems were checked and were up to date this provided evidence that a safe environment had been provided for service users. Discussion with the manager, staff and examination of records confirmed that staff had received training including fire training, and moving and handling which promoted safe working practices and welfare of the residents and their colleagues. Training to update staff with safe practise for administration of medicines had been planned to begin just after the inspection. This was needed to maintain service user safety. 136d Warminster Road DS0000061670.V312406.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 3 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 2 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 3 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 2 X X X 3 x 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 Requirement Medication procedures must be reviewed to ensure that staff administer and sign for medication appropriately. All staff must be trained or as appropriate be offered refresher training in the safe administration of medication procedures. All staff must be trained or as appropriate be offered refresher training in the protection of vulnerable adults. Staff training and development records must be made available for inspection, which are up to date and accurate. A system of reviewing and improving the quality of care must be devised at the service. Regulation 26 visits must be carried out on a regular monthly basis ands these must be then forwarded to the CSCI local office. Timescale for action 31/03/07 2. YA23 12 30/06/07 3. YA35 12, 18 31/03/07 4. YA39 24, 26 31/03/07 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA9 Good Practice Recommendations Records need to be monitored on a regular monthly basis to ensure they are kept up to date. Records need to be monitored on a regular monthly basis to ensure they are kept up to date. 136d Warminster Road DS0000061670.V312406.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 136d Warminster Road DS0000061670.V312406.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!
