Inspection on 09/07/07 for 16 Mansfield Road

This inspection was carried out on 9th July 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

16 Mansfield Road 29/06/06

16 Mansfield Road 01/11/05

16 Mansfield Road 03/06/05

16 Mansfield Road 27/05/04

16 Mansfield Road 13/05/03

Similar services:

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

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

CARE HOME ADULTS 18-65 Mansfield Road (16) Heanor Derby Derbyshire DE75 7AJ Lead Inspector Tony Barker Key Unannounced Inspection 9th & 10th July 2007 09:30 Mansfield Road (16) DS0000020050.V340621.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 Mansfield Road (16) DS0000020050.V340621.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. Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mansfield Road (16) Address Heanor Derby Derbyshire DE75 7AJ (01773) 711270 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) unitedresponce.org@16mansfieldroad None United Response Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th June 2006 Brief Description of the Service: This service provides accommodation for four younger adults with severe learning disabilities and associated conditions including autism, sensory disability and challenging behaviour. Four single bedrooms are provided in a detached house situated on a bus route near to the town centre of Heanor. The fees for the Home are from £991 to £1095 per week. A copy of the last inspection report from the Commission for Social Care Inspection (CSCI) is available, to service users and visitors, in the office. Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 7.5 hours and was a key unannounced inspection. The service users all had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed working with and being cared for by staff. The Senior Support Worker with Additional Responsibilities (SSWAR) and one senior support worker were spoken to and records were inspected. There was also a tour of the premises. One service user was case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection, Annual Quality Assurance Assessment, questionnaire was reviewed prior to this inspection. What the service does well: What has improved since the last inspection? What they could do better: Service users’ care plans must include their personal goals, indicate how these are to be achieved and be kept under review. All potential risks to service users must be subject to a written person centred risk assessment. All staff must be provided with regular Fire Safety training and be supervised at appropriate intervals. The Acting Manager must make application to become the Home’s Registered Manager. Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 6 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. Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 7 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 Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 8 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): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the Home was available to prospective service users, and people placing them, in order to make an informed decision about whether the service is right for them. EVIDENCE: The Home’s Statement of Purpose and Service Users’ Guide were very well designed with plenty of symbols to aid service users’ understanding. A copy of both these documents were on each individual service user’s file. However, the Service Users’ Guide did not include details of fees charged, what they cover and the cost of items not included in these fees. The SSWAR said that service users are expected to pay, from their mobility allowance, the cost of fuel for the Home’s transport. The Service Users’ Guide did not include service users’ views of the Home. There had been no service users admitted since the previous inspection. Previous inspections had identified good quality documentation of the preadmission process. Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 9 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users’ individual plans of care were not person centred, or being reviewed regularly, so they could not be sure that their personal care needs would be fully met. EVIDENCE: The care planning documents for the case tracked service user were examined. The Home’s own care planning documentation was found to be fragmented, not recorded in a format understandable by service users and with documents missing. There was an ‘Involvement Support Profile’, providing a useful record of needs, that had been reviewed in April 2007. ‘Support Plans’ were in place covering ‘Personal Hygiene’ and ‘Behaviour’. These had last been reviewed in February 2006. They contained the only action plans with respect to this service user and could not be considered holistic or ‘person centred’. Daily logs, completed by staff, were brief and appeared not to reflect any particular action plans regarding service users. There was a ‘Likes & Dislikes’ list on file but this stated “Likes all food” without making reference to any food preferences. There were no minutes from any previous formal review meeting, Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 10 regarding the case tracked service user, only notes made prior to a meeting held in 2005. There were minutes from another service user’s review meeting held in November 2006 though these had no signature and no recorded evidence of involvement by the service user or representative. There was just one ‘Person Centred Planning’ file in the Home, relating to another service user but this had been only partially completed. Additionally, the SSWAR produced a blank person centred needs assessment document called a ‘Listen To Me’ workbook, for future use. The SSWAR said he, and all his colleagues, had received training in Person Centred Planning. However, he accepted there had been no move to put Person Centred Planning into action since the last inspection, when the Inspector was first informed of plans to move forward on this method of working. The SSWAR also accepted that the majority of the four service users’ files contained documents that were not being used by staff on a regular basis but pointed out that the Home was awaiting a new filing system from United Response. He also pointed out that staff practice in the Home was person centred as evidenced by, for example, an improvement in the behaviour of the case tracked service user who was experiencing lower levels of anxiety. The senior support worker spoken to gave examples of service users making their own decisions and choices, with staff assistance. These included offering choices of evening activities, both indoor and outdoor, and choosing from a menu in a restaurant. She said that service users vary according to their ability to make decisions about which clothes to wear each morning – one is quite independent in this area while others need more help. As at the last two inspections consideration was still being made to introduce advocates to the service users, the SSWAR said. This was felt to be most important in relation to one service user who had no family involvement, though a befriender was involved. One generic risk assessment was on the case tracked service user’s file. It was not person centred and was worded almost identically to that of other service users’ risk assessments. There was no reference to risks associated with activities outside the Home, for example. Some reference was made to the benefits from taking risks and the senior support worker confirmed some of these benefits - for instance using buses, crossing roads and horse riding. She added that there were plans for the case tracked service user to experience rock climbing on a planned holiday in September 2007. Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 11 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. The Home provided activities and services that were age-appropriate and valued by service users and promoted their independence. EVIDENCE: Two of the service users were being provided with four days a week day service at a Derbyshire County Council establishment and two were receiving a day service from United Response four days a week. On one day a week, service users were being supported by care workers from the Home on a ‘personal day’. The senior support worker spoken to gave examples of service users taking part in activities that were valued by them and fulfilling. The case tracked service user was described as showing pleasure in swimming and this was evidenced by smiles and a generally happy demeanour. Another service user was said to enjoy horse riding and showed pleasure through “happy noises” and a relaxed manner. The senior support worker noted that the imminent closure of the United Response day services would bring about the loss of a ‘snoezelen’ (multi-sensory stimulation) facility that was appreciated Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 12 by the service users each Friday evening. The SSWAR spoke of evening activities at, and outside, the Home being flexible and increasingly individualised, due partly to an increase in evening staffing hours. The Home’s lounge area contained a good supply of games and it was noted that the case tracked service user had a particular liking for jigsaws, as evidenced by a framed jigsaw in the person’s bedroom. Around the premises there was much photographic evidence of service users enjoying activities and holidays with staff. The senior support worker described how service users use local shops, eat at restaurants and go for walks. She said that the case tracked service user was known by a number of local shopkeepers. There was generally good contact between service users and their relatives except for one service user. This person had a befriender who was visiting every three months and they were going out for meals together. Another service user was friendly with a service user from a nearby care home and they meet each week for a meal or drink. Plans were in place, the SSWAR said, for this service user to extend an existing relationship with another service user at another nearby care home. The case tracked service user’s daily routine was displayed on the person’s bedroom wall using words and understandable symbols. The SSWAR said this routine is very important to the service user and this display can be used by staff to help the person to understand aspects of the routine and hence reduce anxiety. Another service user routinely locks the bathroom door when using it. A key is kept above the door, outside, for staff to use in an emergency. The SSWAR provided evidence of daily routines promoting service users’ independence. For instance, one service user takes particular pleasure in the daily routine of emptying and loading the Home’s dishwasher. Food stocks were examined and found to be at a good level, especially fresh fruit and vegetables. The Home’s four weekly rolling menus indicated that meals were balanced and nutritious. The SSWAR said that all service users were involved in food shopping, preparation and clearing up after meals. There were no meals being prepared or eaten during the two mornings of this inspection - service users were eating lunch out with staff on their personal days. Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 13 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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home was providing service users with personal support in the way they preferred and required and was meeting their physical and emotional health needs. EVIDENCE: The senior support worker spoken to described how service users’ privacy needs were respected by, for example, knocking on bedroom and bathroom doors before entering. She also said that the use of public disabled toilets provided greater privacy when staff need to assist. The SSWAR said that plans were now well in hand for changing the use of a small ground floor office to an en-suite shower room, for one service user, in order to provide the person with increased privacy. The senior support worker spoke about her satisfaction at the personal development of the case tracked service user, particularly, in that she could have a conversation with the person now whereas, in the past, there had been no communication. Two handrails were in place on the stairs to maximise service users’ independence and a shower seat met one service user’s needs. This service user had been provided with trousers with an elastic waist as the person was unable to use buttons. There was a communications board in the kitchen that indicated, to service users, the staff on duty, day of Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 14 the week and daily routine by means of ‘stick on’ symbols. The staff on duty were observed treating the two service users, who were having a ‘personal day’, with sensitivity during this inspection – other service users were out at day services. There was evidence on file of a good range, and appropriate frequency, of health checks on service users. Health appointments were being recorded in ‘My Health File’ for two of the four service users. This was a small, compact and well-designed file, in place since early 2007, that was appropriately person centred. Many parts of these files had still to be completed. Further details arising from health appointments were being recorded on ‘Report/Feedback’ sheets. All the service users were attending a ‘well man’ clinic annually. Service users were all described as being generally in good health, with conditions such as diabetes and epilepsy being well controlled. The Home’s medication recording system was examined and was found to be satisfactory. The system of managing and recording ‘prn’ (as and when required) medicines, through individual written protocols, was also satisfactory. A copy of these protocols had been affixed to the door of the medicines cabinet, as recommended at the last inspection. Sample staff signatures were recorded. Medication was being securely stored. The senior support worker spoken to said she had received training in the safe use of medicines within the past 12 months. Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 15 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good procedures for handling complaints and abuse were in place ensuring service users were fully protected. EVIDENCE: The Home’s complaints procedure was displayed in the entrance hall. It was satisfactory and included some symbols to help with service users’ understanding. The Service Users’ Guide contained a most comprehensive and commendable complaints procedure that included six examples of things that a service user may be unhappy about. For example, “Things you would like to do but you cannot do them” and “If there are people who are not kind to you”. The SSWAR stated that there had been no complaints received by the Home. An appropriate complaints record form was available for such use. The Home’s staff training matrix indicated that all staff had attended training on keeping adults safe from abuse, except that the Manager and one senior support worker had not had recent refresher training. The senior support worker showed awareness of the Home’s ‘Whistle Blowing’ policy but was unsure whether United Response would be supportive following whistle blowing. It was clear she had not read the policy for a while. The Home had a satisfactory written policy on responding to incidents of abuse and Derbyshire Reporting Forms and the CSCI Safeguarding Adults Protocol and Alerting Forms were in place. There had been no physical restraint used on service users for three years, the SSWAR explained. He said all staff had been provided with training in reducing incidents of physical intervention, and this was confirmed by records. Records of the case tracked service user’s monies Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 16 were checked and it was noted that good recording and monitoring practices were being followed. Mansfield Road (16) DS0000020050.V340621.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 good. This judgement has been made using available evidence including a visit to this service. Service users were living in a clean, homely and comfortable environment that met their needs. EVIDENCE: The Home was attractively furnished and had a homely feel to it. Two bedrooms, used by service users with continence management problems, had vinyl flooring with a domestic carpet appearance. Replacement windows had been fitted since the last inspection. The SSWAR stated that a full redecoration of the Home was imminently due. All bedrooms were attractive and personalised. In one bedroom the ceiling was in need of redecoration following damage from a water leak. In another bedroom there was no towel rail as this had been recently broken, the SSWAR said. The laundry room contained a washing machine and dryer. The washing machine had a sluicing programme. There were no unpleasant odours in the Home at the time of this inspection. The Home was clean and hygienic. The member of staff spoken to described reasonable infection control practices but Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 18 was not aware of the Home’s policy of using yellow bags, as described by the SSWAR. Mansfield Road (16) DS0000020050.V340621.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): 32,33,34,35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff group was stable and well-recruited but inadequate training and supervision put service users at risk. EVIDENCE: Four out of the six care staff had achieved a National Vocational Qualification (NVQ) to level 2 or above. One was currently completing this course. This meets the National Minimum Standard to maintain a staff group with at least 50 qualified staff. The SSWAR said that continuity of staffing had improved since the last inspection. This had been the result of a permanent member of relief staff being in post who was providing flexible hours. The staffing rota was not examined in detail and an assessment of the adequacy of staffing levels was not made. The SSWAR confirmed that plans to reduce staff on the morning shift from two to one had not been carried out, as planned at the last inspection. No staff had been appointed since the last inspection, when good recruitment and selection practices were being followed. Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 20 The SSWAR stated that all staff had been provided with mandatory training except that no staff, including night staff, had been provided with Fire Safety training since January 2006. The senior support worker spoken to confirmed she last had Fire Safety training in 2005. She gave details of those training courses she had attended over the past 12 months. There was evidence, as at the last two inspections, that not all staff were being provided with formal supervision at the appropriate interval of two months. The SSWAR stated that he was receiving supervision at approximately three monthly intervals. Mansfield Road (16) DS0000020050.V340621.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): 37,38,39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home’s Acting Manager was not registered with the CSCI and had therefore not proved himself fit to manage the Home and hence ensure the health, safety and welfare of the service users. EVIDENCE: The Acting Manager of the Home had 16 years experience of working with people with learning disabilities and had an NVQ in Care and Management at level 4. However, he was not registered. He had made application in early 2007 to the CSCI, to become the Registered Manager, but this application had not been received. The SSWAR stated that, “the Home runs very well” and said evidence of this was the service users’ improved behaviour. He was positive about the Acting Manager and said he was appreciative of the level of delegated responsibilities Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 22 given to him. The Senior Support worker spoken to was positive about the staff team. Records of the monthly, unannounced audit visits to the Home, undertaken on behalf of the Registered Provider, were examined. These were very brief and had no record of interviews with staff. An additional quarterly management audit was also being undertaken. A 2005-06 Service Plan was in place but there was no evidence of it being reviewed or of a current Service Plan. The SSWAR said that all United Response staff complete annual satisfaction questionnaires. He was not aware of questionnaires being sent to service users’ relatives or care managers. However, he stated that service users’ next of kin are sent a copy of the Home’s complaints procedure, and a complaints form, each year. Cleaning materials were being safely stored in locked cupboards. Good food hygiene practices were being followed, including safe food storage and the monitoring of refrigerator and freezer temperatures. Monthly environmental hazard checks were being made and records of monthly fire drills and weekly fire alarm tests were also in place. Electrical and gas equipment was being checked at appropriate intervals. Mansfield Road (16) DS0000020050.V340621.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 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 4 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 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 3 X X 3 X Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 25 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(2)(b) Requirement Service users’ care plans must include their personal goals and indicate how these are to be achieved. They must be kept under review, with recorded evidence of this, so that they reflect current personal needs, wishes and risks. All potential risks to service users must be subject to a written person centred risk assessment so as to ensure their health and safety. (Previous timescale was 01/09/06) All staff must be provided with annual Fire Safety training, and night staff with twice yearly Fire Safety training, to ensure the safety of staff and service users in the event of fire. All staff must be supervised at intervals of two months to ensure that they are following good and safe practices in the Home. (Previous timescale was 01/09/05) The Acting Manager must make application to become the Home’s Registered Manager. This is in order to provide the CSCI with evidence that he is fit to manage the Home and ensure the health, safety and welfare of its service users. Timescale for action 01/10/07 2. YA9 13(4)(c) 01/09/07 3. YA35 23(4)(d) 01/10/07 4. YA36 18(2) 01/10/07 5. YA37 CSA 11(1) 01/08/07 Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 26 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 YA1 Good Practice Recommendations The Service Users’ Guide should include details of fees charged, what they cover and the cost of items not included in these fees. It should also include service users’ views of the Home. Recording standards on service users’ files should be improved. (This was a previous recommendation) Care plans should be holistic and person centred, including risk assessments. Daily logs should reflect service users’ personal action plans. Care plans should be reviewed with the involvement of service users together with relatives, advocates or other representatives. Evidence of this involvement should be in the form of a signature. (This was a previous recommendation) Each service user’s plan of care should be recorded in a language and format suitable to each individual and the relevant service user should hold a copy. However, if this is inappropriate a copy should be given to the family/professional representative to sign. The Manager should record the reason for this within the care plan. (This was a previous recommendation) Consideration to the introduction of an advocate to one particular service user should be prioritised. United Response should consider an alternative to the present ‘snoezelen’ (multi-sensory stimulation) facility that is planned to close. All staff should be provided with up to date refresher training on keeping adults safe from abuse. Staff should be reminded of the Home’s ‘Whistle Blowing’ policy and receive their own copy of this. Attention should be given to the damaged bedroom ceiling and missing towel rail, as discussed in this report. All staff should be made aware of the Home’s policy of using yellow bags in order to ensure safe infection control practices. DS0000020050.V340621.R01.S.doc Version 5.2 Page 27 2. 3. 4. 5. YA6 YA6 YA6 YA6 6. YA6 7. 8. 9. 10. 11. 12. YA7 YA12 YA23 YA23 YA24 YA30 Mansfield Road (16) 13. 14. 15. YA39 YA39 YA39 The monthly, unannounced audit visits to the Home, undertaken on behalf of the Registered Provider, should include interviews with staff and these should be recorded. A Service Plan for 2007/08 should be developed. Satisfaction questionnaires should be sent to service users’ relatives and care managers. Mansfield Road (16) DS0000020050.V340621.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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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