Inspection on 08/05/08 for 17 Ella Bank Road

This inspection was carried out on 8th May 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

17 Ella Bank Road 02/07/07

17 Ella Bank Road 17/08/06

17 Ella Bank Road 25/10/05

17 Ella Bank Road 11/03/05

17 Ella Bank Road 14/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 06/08/2009.

CARE HOME ADULTS 18-65 Ella Bank Road (17) 17 Ella Bank Road Heanor Derbyshire DE75 8HF Lead Inspector Tony Barker Unannounced Inspection 8th May 2008 09:30 Ella Bank Road (17) DS0000019979.V365287.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 Ella Bank Road (17) DS0000019979.V365287.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. Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ella Bank Road (17) Address 17 Ella Bank Road Heanor Derbyshire DE75 8HF (01773) 760806 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) maureen.foster@unitedresponse.org.uk None United Response Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category: Learning disability - Code LD. The maximum number of service users who can be accommodated is 3. 2. Date of last inspection 2nd July 2007 Brief Description of the Service: 17 Ella Bank Road is a detached house situated on a residential road on the outskirts of Heanor. Service users are provided with adequate accommodation and single rooms. There is a rear garden. Ella Bank Road offers personal and social care to people with a severe learning disability with associated conditions that may include autism, sensory disability or challenging behaviour. Activities are planned to meet individual needs. Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The time spent on this inspection was 9 hours and was a key unannounced inspection. Survey forms were posted to service users’ relatives, staff and external professionals before this inspection. One relative and four staff returned completed surveys. 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. Two care managers was spoken to on the telephone following this inspection. The Acting Manager, 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 (AQAA), questionnaire was reviewed prior to this inspection. The fees for the Service are from £1149 to £1513 per week and stated in service users’ Individual Charter. 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. What the service does well: What has improved since the last inspection? The Home had been redecorated and floor coverings replaced in most ground floor rooms. Written care plans had improved significantly and were very Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 6 person centred. Some improvements had been made to the recording of medicines administered to service users to ensure their health and welfare. The Acting Manager had applied to be registered with the Commission. Three of four requirements and eight recommendations, made at the previous inspection, had been met. Additionally, four further recommendations had been partially met. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ella Bank Road (17) DS0000019979.V365287.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 Ella Bank Road (17) DS0000019979.V365287.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 Service 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 Acting Manager produced copies of the Service’s Statement of Purpose and Service Users’ Guide which had been reviewed in late 2007. These used a mixture of text and symbols so they could be more understandable to the individual service users. Each service user had their own Individual Charter available to them – these used ‘Picture Bank’ pictures to aid their understanding of the service provided. There had been no service users admitted since the previous inspection. The Acting Manager confirmed he was aware of the need to ensure that a full assessment of need is provided before admission, in order to guide staff in meeting the person’s needs. Ella Bank Road (17) DS0000019979.V365287.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 good. This judgement has been made using available evidence including a visit to this service. Service users’ individual plans of care were person centred, and were being reviewed regularly, so they could be sure that their current needs and preferences were being fully met. EVIDENCE: The Service’s care planning documents had improved considerably since the previous inspection. The Service was operating to a ‘person centred’ model for individual care plans, periodic reviews of need and action to be taken and for risk assessments. For instance, a ‘Communication Chart’ for the case tracked service user helped staff to identify what the person was thought to mean when communicating something. Care plans were holistic and gave comprehensive guidance to those who support the person. They clearly identified goals to work to and were being reviewed every six months to ensure that current needs were being focussed on. Monthly summary sheets had also been introduced and weekly ‘Keeping Track’ forms were examined. All these documents indicated that regular monitoring of individuals’ needs and preferences was taking place. Staff had been provided with training in ‘Person Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 10 Centred Planning’ and this was confirmed when speaking to a senior support worker. A senior support worker gave examples of service users making their own decisions and choices, with staff assistance. These included service users making small individual decisions at bath time. We observed one service user going out with a member of staff and then soon returning after deciding this was not their preferred activity at that time. Risk assessments were recorded in a person centred way - they included columns headed ‘Important to me’ and ‘Important for me’. These were comprehensive though they did not reflect elements of risk for the case tracked service user while out in the community. For instance, the person was said by staff to “love talking to strangers” and there were also “road safety issues”, though staff always accompanied the service user when out. One senior support worker confirmed that service users benefit from taking ‘responsible’ risks. She gave an example of the case tracked service user requesting to use the small pool at the local leisure centre. Ella Bank Road (17) DS0000019979.V365287.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 Service 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 the third was receiving a similar day service three days a week. On other week-days, service users were being supported by care workers from the Service, with a view to increasing involvement in the local community. Voluntary work opportunities for service users were being sought, the Acting Manager explained. There had been trials of one service user taking a local dog for a walk, assisted by a member of staff and this was benefiting the person, staff confirmed. There were plans for this service user to be introduced to an animal rescue kennel to further pursue this interest. The senior support worker spoken to gave examples of service users taking part in activities that were valued by them and fulfilling. For example, the case tracked service user Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 12 was said to enjoy offering help with domestic tasks and this was being encouraged. There was evidence of continuing service user involvement in the local community. The Acting Manager recorded in the AQAA that there was increased community presence and participation and he spoke, at the inspection, of service users being more involved in shopping. He went on to describe other initiatives such as plans for service users to help out at local Brownie pack meetings. One senior support worker described how service users go to local shops, cafés, hairdressers, swimming pool and bowling alley. She said that the case tracked service user was very fond of MacDonalds restaurant will choose between items pointed out by staff. There was generally good contact between service users and their relatives, the Acting Manager said. There were plans to review one service user’s contact with a close family member and another had improved contact with a relative. Two service users have a befriender too who had been a staff member at a previous care home and takes the service users out for meals as well as attending care plan review meetings as an advocate, to ensure their views are fully taken account of. This person is being asked to act as an advocate for the case tracked service user too as part of the Service’s person centred planning initiatives. One senior support worker provided evidence of daily routines promoting service users’ independence. These included the case tracked service user making sandwiches and coffee as well as involvement in other domestic tasks. Three staff who returned completed surveys to us referred positively to the Service supporting service users to have as independent a life as possible. Food stocks were examined and found to be adequate. These included fresh fruit and vegetables. Menus indicated that meals were balanced and nutritious. The food preferences of service users were on file. The Acting Manager confirmed that all service users were involved in food shopping, preparation and clearing up after meals. There had been an anonymous complaint raised with us, prior to this inspection, about one service user’s eating habits that the Service was not adequately addressing. Evidence at this inspection indicated that this matter was being addressed appropriately and this was confirmed independently by the person’s Social Services care manager. However, there was no note on the service user’s care plan of how the matter should, or was, being managed. It was clear to us that this person’s health needs were being properly dealt with and their need to display independence was being respected. Ella Bank Road (17) DS0000019979.V365287.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 adequate. This judgement has been made using available evidence including a visit to this service. Inadequate written guidance on medication administration, and unsafe storage of medicated creams, mean that service users may not receive the medication prescribed for them, thereby putting them at risk of harm. The Service was providing service users with personal support in the way they preferred and required. EVIDENCE: One senior support worker spoken to confirmed that service users’ privacy needs were met. She gave the example of one service user saying, “Go away” to staff if wishing to be alone in their bedroom. She also spoke of staff giving service users opportunities to “have a soak in the bath in private” – with staff staying close by and with a written risk assessment to address this. Handrails were in place to maximise service users’ independence in front of the premises and these had been painted so they looked less institutional. Service users’ likes and dislikes were recorded on file. There had been two incidents this year when a service user had threatened staff with a knife. The Service had responded appropriately by reviewing the risk assessment and moving knives to a less accessible place. However, we had not been informed of these potentially serious incidents that may have adversely affected other service Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 14 users’ safety. Such notifications ensure that the Commission is able to carry out its regulatory responsibilities. The Acting Manager stated in the AQAA that, “Staff approaches have enabled the people we support to be more confident and they now communicate their needs and wishes in a more positive way, reducing the number of incidents of challenging behaviour”. The case tracked service user’s care plan reflected this improvement. We observed positive interactions between staff and all service users on the day of the inspection. There was evidence on the case tracked service user’s file of a good range, and appropriate frequency, of health checks. Health appointments were being recorded in ‘My Health File’. This was a small, compact and well-designed file, in place since early 2007, that was appropriately person centred. These files were being fully used to ensure monitoring of health needs and action taken. Further details arising from health appointments were being recorded on ‘Report/Feedback’ sheets. A referral had been made to a Speech & Language Therapist to ensure that one service user’s request to change their day service provision was really what the person wanted. This was evidence of good person centred planning. The medication recording system was examined and the system of recording ‘prn’ (as and when required) medicines had improved since the previous inspection so as to indicate that people were receiving medication appropriate to their needs. However, there was no ‘prn’ Protocol sheet in place regarding Lorazepam administered ‘prn’ to one service user, although it was later found on computer and then printed off. A ‘prn’ Protocol sheet was in place regarding Procyclidine Syrup that had ceased to be used for the past 6-8 weeks. An Urgent Action letter was sent to the Registered Provider on 12 May 2008 concerning this matter. This latter protocol did not make reference to the maximum dose to be administered over a 24-hour period – this was important, to ensure unsafe doses of medicine are not administered. This had been an issue at the previous inspection. Also, as at the previous inspection, the Acting Manager could find no United Response written procedures covering the use of ‘prn’ medicines. Three opened tubs of Sudocrem were found in the case tracked service user’s locked bedroom cabinet – none had been dated when opened so as to indicate when the 28 day expiry had occurred. A similar problem was found at the previous inspection. An Urgent Action letter was sent to the Registered Provider on 12 May 2008 concerning this matter. Sample staff signatures were recorded to ensure clarity on medicine records. Medication was being securely stored. All staff had received training in the safe use of medicines. Ella Bank Road (17) DS0000019979.V365287.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. Procedures for handling complaints and abuse were in place to make sure that service users were being protected. EVIDENCE: The Service’s complaints procedure was displayed in the entrance hall. It was satisfactory and included some symbols to help with service users’ understanding. Some elements of it needed updating though the version on service users’ files was up to date. The Acting Manager was informed of the anonymous complaint raised with us, prior to this inspection, about one service user’s eating habits. He was later informed that no further action would be taken as Social Services had found the complaint to be unsubstantiated. The Acting Manager stated that there had been no complaints received by the Service up to the date of this inspection. An appropriate complaints record form was available for such use. At this inspection additional time was spent on exploring the Service’s policies and procedures around safeguarding adults. This was a national drive for the Commission during two weeks in May. A senior support worker confirmed she had received training in safeguarding adults and showed awareness of this area and of the Service’s ‘Whistle Blowing’ policy. She confirmed she had received a reminder about the latter policy at a team meeting. The Acting Manager stated that he and all care staff had been provided with training on keeping adults safe from abuse and records supported this. There was a satisfactory written policy on responding to incidents of abuse and Derbyshire Reporting Sheets were in place. The Acting Manager and the senior support Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 16 worker spoken to both showed awareness of the Service’s policy. A record of the physical restraint used on one service user was examined and found to be satisfactory. This was a record newly developed for incidents of restraint. Ella Bank Road (17) DS0000019979.V365287.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 safe, hygienic and reasonably well maintained environment, which was furnished to a good standard. EVIDENCE: The Home was attractively furnished and had a homely feel to it. It had recently been redecorated and floor coverings replaced in most ground floor rooms. Carpets in two service users’ bedrooms were rucked and stained, as at the previous inspection. The Acting Manager said that these were soon due to be replaced. All bedrooms were attractive and personalised. An airconditioning unit had been fitted in one bedroom to address the needs of a service user. A number of radiator top covers were damaged and this matter was also being addressed, the Acting Manager said. The rear garden was tidy and had a double swing and trampoline. The swing was being used and enjoyed by one service user during this inspection. The laundry room contained a washing machine and dryer. One senior support worker described good practice regarding the transportation of infected Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 18 materials around the Home. There were no unpleasant odours in the Home at the time of this inspection. The Home was clean and hygienic. Ella Bank Road (17) DS0000019979.V365287.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): 32,34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Service’s level of staff training, and quality of recruitment, fell short of fully safeguarding the welfare of service users. EVIDENCE: Eight of the nine permanent and two relief care staff had achieved a National Vocational Qualification (NVQ) to level 2 or above. This met the National Minimum Standard to maintain a staff group with at least 50 qualified staff. There was evidence, from staffing rotas, that one member of staff was due to work excessive shifts on each of three days in the four forthcoming weeks: from 8am to 9.30pm, on average. The potential risks to service users, apart from the effects of staff tiredness, were discussed with the Acting Manager. He said this was due to planned staff annual leave or existing staff sickness. Other aspects of this standard were not assessed at this inspection. Two staff files were examined – one of these did not contain any form of the staff member’s identity or evidence of a Criminal Records Bureau (CRB) disclosure. This lack of robust procedures could potentially put service users at risk. However, we are aware that United Response normally follows safe and Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 20 robust procedures in the recruitment of new staff and their recruitment practices were described as commendable at the previous inspection. A senior support worker confirmed that she had been asked to provide all necessary documents at the time of her appointment. One service user had been involved in this recruitment process –the candidate’s positive response to the person supported the decision to appoint her. The file of the support worker, appointed in October 2007, indicated that she had followed the Skills for Care Common Induction Standards so ensuring she had relevant job competencies. She was to be put forward for training at NVQ level 2 to build upon these competencies, the Acting Manager stated. Records supported that all staff had been provided with mandatory training except that Fire Safety training, undertaken by a competent person, had not been provided to two staff since May 2006 and to four staff since January 2006. An Urgent Action letter was sent to the Registered Provider on 12 May 2008 concerning this matter. In house Fire Safety training had been provided. The senior support worker who was spoken to said she had attended a range of mandatory training courses over the previous 12 months. Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Service was generally well managed so that service users were protected and their best interests were promoted by the systems in place. EVIDENCE: The Acting Manager had 17 years experience of working with people with learning disabilities and had an NVQ in Care and Management at level 4. His application to become the Registered Manager had just been received at the time of writing this report. The AQAA, completed by the Acting Manager, was very comprehensive and detailed. It clearly set out the changes made within the Service and the areas in which they still need to make improvements. Records of the monthly, unannounced monitoring visits to the Home, undertaken on behalf of the Registered Provider, were examined. These were satisfactory. An additional quarterly management audit was also being Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 22 undertaken and a Service Plan for 2008/09 had been drafted. These quality assurance measures indicated that due attention was being given to systematic Service reviews. Additionally, the Acting Manager said that staff and relatives had completed satisfaction questionnaires. One relatives survey was returned to us before the inspection - this was positive about the Service. The Service had sent no satisfaction questionnaires to care managers or other external professionals. However, two care managers who we telephoned following this inspection were both very positive about the quality of care provided to their respective client. One said, “I am extremely satisfied…(my client) is healthy and well cared for…an excellent service”. The other said their client’s “views and wishes are taken into consideration…they take a person centred approach…staff are friendly and have a good relationship with service users”. Cleaning materials were being safely stored in locked cupboards under the laundry room sink and Product Information Sheets were kept in the office near by. A sheet of first aid measures to be taken in the event of an accident with cleaning materials was kept on the laundry room notice board. Good food hygiene practices were being followed. Accident records were being appropriately maintained and environmental risk assessments were in place. Records of monthly fire drills and weekly fire alarm tests confirmed these were being carried out. Ella Bank Road (17) DS0000019979.V365287.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 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 3 33 X 34 2 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 1 X 3 X 3 X X 3 X Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Timescale for action 16/05/08 2. YA20 13(2) 3. YA34 19(1)(b) Sch.2.1 & 2.7 4. YA35 23(4)(d) Staff must be provided with accurate, consistent and up to date written guidance on medication administration to ensure that people receive the correct medication prescribed for them. There must be a date of opening 16/05/08 recorded on all medication with a reduced expiry once opened to ensure the safety of service users. (Previous timescale was 01/08/07) Staff must not be appointed 01/07/08 before proof of the person’s identity and a CRB disclosure are obtained. This ensures that all efforts have been made to satisfy the Service that the person is fit to work and service users are safe. All staff must be provided with 01/08/08 Fire Safety training at least once a year, and twice yearly when undertaking night care shifts, so as to ensure their awareness of preventing fires. Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard YA9 YA17 YA18 YA20 YA20 YA22 YA33 YA39 Good Practice Recommendations Risk assessments should reflect all potential risks to which service users may be exposed. Care plans should make explicit the ways by which elements of challenging behaviour are managed. The Commission should be informed of any incidents that may adversely affect service users’ safety. Individual written protocols, regarding the administration of all ‘as and when required’ medication, should make reference to the maximum dose in any 24 hour period. There should be a written procedure covering the safe use of ‘as and when required’ medicines. The Service’s complaints procedure, displayed in the hall, should be updated. Wherever possible, staff should not work excessive shifts, due to potential risks to service users. Satisfaction questionnaires should be sent to service users’ care managers or other external professionals. Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG 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 Ella Bank Road (17) DS0000019979.V365287.R01.S.doc Version 5.2 Page 27 - 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. 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