Inspection on 27/09/07 for 17 Jervaulx Road

This inspection was carried out on 27th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

17 Jervaulx Road 09/08/06

17 Jervaulx Road 08/11/05

17 Jervaulx Road 18/07/05

17 Jervaulx Road 25/01/05

17 Jervaulx Road 24/08/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 17 Jervaulx Road New Skelton Saltburn by the Sea Cleveland TS12 2NL Lead Inspector Brenda Grant Key Unannounced Inspection 27th September 2007 10:00 17 Jervaulx Road DS0000031330.V351079.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 17 Jervaulx Road DS0000031330.V351079.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. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 17 Jervaulx Road Address New Skelton Saltburn by the Sea Cleveland TS12 2NL 01287 653814 01287 653817 ann_bewick@redcar-cleveland.gov.uk 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) Redcar and Cleveland Borough Council Position Vacant – manager application, for registration, in progress Care Home 18 Category(ies) of Learning disability (18) registration, with number of places 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2006 Brief Description of the Service: Jervaulx Road is a modern, purpose built, two storey building, comprising of four separate units interlinked by internal corridors housing staff sleep in rooms, office and laundry facilities. Each unit provides a distinct service. One unit is for those residents requiring long term care, two units provide respite care and the fourth unit offers accommodation to one resident who may require admission to the home in the event of an emergency/crisis. Accommodation is provided in eighteen single rooms. Bedrooms do not contain en-suite facilities. Communal space in two of the units consists of a kitchen/dining room and a lounge. The third unit consists of a dining kitchen and two lounges and the emergency/crisis unit has a small lounge/dining room. Kitchens are domestic in nature and accessible to residents. Externally there is a lawned garden with shrubs, rockery seating and patio area. The home is located near to the centre of Skelton and is close to local amenities and bus routes. At the time of the inspection, the fees charged by the home ranged from £0 to £15 per night and £63.95 to £98.60 per week. The fee for a daytime meal was £2.55. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection. We assessed the information from: the Annual Quality Assurance Assessment that was completed by the manager, six survey forms that had been completed by service users and five forms completed by a relative of a service user and we carried out a visit to the home. The visit took place over one day, seven hours in total. Discussion and observation took place with service users, staff, a coordinator and the manager. We looked around the home as well as examining a number of records which included those for; service users and staff files, health and safety and maintenance checks, complaints, accidents and medication. The findings from the inspection were of the manager and staff providing a good care service, creating a comfortable, homely atmosphere and making every effort to meet the needs of individual residents. What the service does well: What has improved since the last inspection? The systems for storage, recording, handling and administration of medicines had been improved. Some maintenance work in bathrooms, toilets and showers had been carried out. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 6 Recruitment and selection procedures were better. The manager is undertaking the registration process, to become a registered manager. 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. 17 Jervaulx Road DS0000031330.V351079.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 17 Jervaulx Road DS0000031330.V351079.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standard 2 Service user’s individual aspirations and needs are mostly assessed before they are admitted to the home. EVIDENCE: A sample of service user’s files were examined. All but one file had assessment documentation. The manager said, that person had been transferred from another home and an updated assessment had not been carried out. The assessments, that were available, had been completed by a care manager and the documentation was shared with the home. The assessments included details of the person’s personal, health and social care needs and general information. Details also included particulars about the person’s abilities. There was evidence that the service users and their relatives had been fully involved with the assessment process. The assessment details allowed the home to determine if the person’s care needs could be met by the service. The manager said, before admission, service users were given details about the home and they were invited to visit the home. They could look around the building and meet staff and the other residents before they decide if they want to stay at 17 Jervaulx Road. New service users were invited to stay for a meal, 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 9 this could include service user’s families also having a meal, and service users were sometimes offered an overnight stay. Service users files included an ‘Induction and Guide’. The document had pictures to help service users understand what was written. The ‘Induction and Guide’ was used to assist service users with settling in and to make sure service users knew all of the relevant information about the home and the services that were provided for them. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 6, 7 & 9 The home has Care Plans, for each service user, which are not always regularly reviewed. The plans also contain a Risk Assessments that include how risks are managed. Service user’s files inform how they are supported and assisted with making decisions and living their lives independently, as they are able to, within their capabilities. EVIDENCE: The sample of Care Plans, that were examined, had information of the person’s care needs and how care was to be delivered. There were also details about the person’s preferred lifestyle, choices and likes and dislikes. Care Plans included Risk Assessments, detailing how risk would be minimised to an acceptable level. Areas of risk were discussed with service users, to avoid limiting service users with their preferred chosen activities. Risk Assessments and Care Plans were not always reviewed at least every six months. The 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 11 manager informed, there were some service users who did not stay at the home very often and their Care Plans did not always have regular reviews. Service users were fully involved with their Care Plans. One service user, when s/he saw us with his/her file, said, “That is mine”. The service user showed us all of the documentation and s/he knew exactly what had been written. A member of staff said, service users and their relatives were always involved with the Care Plans and they had the opportunity to give their views about how care was delivered. Staff said, they supported service users with making decisions and choices were offered to service users. One service user we spoke with said, of the staff, “They help me when I want it”. In a survey a relative confirmed, the care service supported people to live their lives as they choose. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 12, 13, 15, 16 & 17 Staff appropriately support and care for service users. Service users are offered choices of daily activities and service users can live their lives as they wish. Records did not make it clear that service users have a varied and healthy diet. Mealtimes are enjoyable. EVIDENCE: Service users had opportunities for personal development and they were encouraged to be independent and maintain practical life skills. Sometimes service users helped with daily jobs around the house. One service user said, “I do some cooking and I help around the place”. The manager and a member of staff said, service users were encouraged and assisted to take up opportunities that would help them to maintain their independence. In a survey, a relative commented, “They try to encourage people to be as independent as possible”. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 13 Service users said, they could choose when to get up and go to bed and do what they wanted each day. Six service users, in a survey confirmed, they can do what they want each day. On the day of the inspection ‘site’ visit some service users were at their day care placements and other service users stayed at home. One service user had decided to stay in bed until mid morning. The manager said, “Where possible, we encourage service users to be involved with the community and go to college and day care but it depended on the service user’s individual needs”. Staff supported service users with their chosen leisure activities, going shopping, trips out and with other interests and hobbies. One service user was eager to show us a football goal post and a basketball net that were in the garden at the back of the home. S/he said, “I am setting up a football team”. One relative, in a survey commented, “The home does well at organising days out and holidays”. Activities, that service users were involved with, were as a group or on an individual basis. Staff supported service users, who lived at the home on a long term basis, with choosing, planning and going on an annual holiday. 17 Jervaulx Road had a car and use of a mini bus, so that service users could be supported with travelling further away from the home. The relative of a service user confirmed, s/he is always kept up to date with important issues that affect the service user. Staff said, the home assisted and encouraged service users to keep their family links and friendships. The manager said, “The home had a pay-phone and a cordless phone was available for service users who wanted to talk to people, in private, in their rooms”. We observed a good relationship between staff and service users and staff spoke to service users in a respectful way. A member of staff said, the home made sure service users had the right to privacy. Service users were offered a key for the lock of their bedroom door and they could lock the doors if they wished. The manager said, service users were encouraged to have a healthy diet. We heard a member of staff encouraging a service user to have fruit, after lunch, rather than him/her having another sandwich and the service user was happy with the alternative. A service user said s/he liked all of the food and a relative commented, in a survey, “Food is varied and nicely presented”. One resident said, “The food is really nice”. There was a planned menu for the cooked evening meal and other meals were made as required by the service users. The home had menu boards, in each unit, which informed service users of the evening meals. There were records of evening meals but there were no details of lunchtime food that was served at the home. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 18, 19 & 20 There is satisfactory support for health and personal care and there is suitable recording of medication. EVIDENCE: The manager and a member of staff said, they supported service users with all personal and healthcare needs. Many service users could manage their own personal care but there were times when staff needed to give prompts. Staff said, personal care is always carried out in a sensitive manner and to the service user’s preferences. In a survey, a relative commented, “Personal care is excellent” and six service users, in a survey, confirmed staff treated them well. Service users chose their own clothes and service user’s appearance reflected their personality. In a survey, a relative commented, “Clothing is changed when necessary and wardrobes and drawers are kept in an orderly fashion”. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 15 The home kept records of all healthcare needs and for service user’s appointments with healthcare professionals. There was information relating to the outcome of medical appointments and, when necessary, Care Plans were updated. Records showed there were regular checks for dental, optical and other healthcare related treatment. A relative, in a survey, confirmed that service user’s health care needs were properly monitored by the care service. Medication Administration Records were examined. The record had signatures of the staff who had administered the medicine to the service users and there was a record of all medicines at the home. 17 Jervaulx Road had a satisfactory facility for storing medicines. The home carried out Risk Assessments, to determine if service users would be capable of looking after their own medicines. At the time of this inspection there were no service users who were in charge of their medication. Staff’s files confirmed staff had completed training for safe handling of medicines. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 22 & 23 Service users are confident their views are listened to and acted upon but the Complaints Procedure has not been updated. Service users are protected from abuse, neglect and self-harm but some staff training was a long time ago. EVIDENCE: The home had a Complaint’s Procedure that was shared with service users and their relatives. The procedure wrongly informed the Commission for Social Care Inspection would investigate complaints. The commission carry out inspections and will investigate matters that are a breach of regulations but will not necessarily investigate individual complaints. The manager informed us, the Local Authority was to issue a new Complaints Procedure that gives correct and up to date information. The procedure informed who would deal with complaints and the expected time when a complainant could expect a written response. A relative, who completed a survey, confirmed s/he knew how to make a complaint and s/he had confidence the home would take appropriate action when it was needed. A service user, in a survey commented, “I can talk to any staff if I am not happy”. There had been no complaints during the last 12 months. The home’s complaints investigation records were kept in a file but they were not in the order of when complaints were received. It could not be easily determined which was the most recent complaint but we found there had been no complaints since 30 August 2005. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 17 The home had a copy of the Redcar & Cleveland Inter-Agency Policies, Procedures and Practice Guidance, ‘No Secrets’, for safeguarding adults. A member of staff said, s/he was aware of the guidelines and s/he had completed training for the protection of vulnerable adults. Staff’s files confirmed staff had completed safeguarding training, for the protection of vulnerable adults, but the training had been a long time ago. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards: 24 & 30 The home environment is homely, comfortable and safe and some, but not all, repairs and maintenance work is carried out. EVIDENCE: Service users lived in a very homely and comfortable home. In a survey, a relative commented, “It has a very ‘home from home’ feel about it which is very important” and another relative wrote, “Rooms are spotlessly clean”. We saw that each bedroom had service user’s own personal belongings and each room was differently furnished and decorated. Some maintenance work had been carried out but we noticed there were areas that needed further improvements. The carpet, near the outside door of the lounge in unit B, was worn and stained and the hall carpet of that unit was stained. The manager told us there were plans to replace the lounge carpet in the doorway area and the hall carpet was to be cleaned, as part of the home’s cleaning programme. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 19 Unit C had a stained kitchen wall, the extractor above the cooker was grubby, the kitchen units were chipped and some of the kitchen unit doors and drawers did not close properly and a lounge had wall-paper peeling off. The day after the inspection ‘site’ visit, the manager informed us that maintenance work had been carried out for: a ground floor bathroom radiator that was rusty, the leaking shower and the first floor toilet cistern cover that was stained. A service user, who had a bedroom on the first floor, insisted his/her bedroom door should be held open. One the day of the inspection site visit the door had been wedged open. The next day, the manager informed us a proper ‘hold opener’ device, that met fire regulations, had been fitted to the door. We saw the wall of a ground floor toilet had been scrapped and paintwork was scuffed. In a survey, a relative commented the toilet had been in that state for some considerable time. The manager told us there were plans to refurbish the toilet, so that it would be more accessible, it would then be decorated. The garden was well maintained and the patio had plenty of seating with tables, available to service users, to sit outside in warm weather. The garden was accessible to wheelchair users. A resident said, “It’s a lovely garden”. 17 Jervaulx Road had plenty of space for residents to move around the home. Service users were seen freely moving around all communal areas. The premise was clean, tidy and free from offensive odours. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 34, 35 & 36 Service users are protected and supported by the home’s recruitment procedures but staff’s files do not always have all of the required information. Staff are appropriately trained to care of the service users at the home but staff do not always benefit from regular one to one supervision. EVIDENCE: Staff files had records confirming staff had completed all of the required induction and basic training. It was commendable that all of the care staff had achieved at least National Vocational Qualifications Level 2. The manager had made arrangements for staff to keep up to date with their training, particularly for: fire drills, first aid, food hygiene, health and safety and infection control. Staff had completed extra training so they had greater awareness and knowledge of resident’s specific disabilities and needs. There was fourteen female and two male staff. Service users benefited from the home having a staff group who worked well as a team. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 21 Service users were supported and protected by the home’s recruitment policy. The Human Resources Department confirmed, staff had satisfactory Criminal Record Bureau checks and references before they started work. Staff files did not always have: copies of passports and birth certificates, history of employment and a recent photograph. The sample of staff files, that were examined, showed there had been one to one supervision but it had not taken place at least six times yearly. The manager said she was planning a programme, for all staff’s one to one supervisions, so that there would be an up to date record to show how often supervisions took place. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 37, 39 & 42 Service users benefit from a well run home and they are included with developments and changes that take place. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager had many years of experience as a deputy manager of a care home. She had successfully gained National Vocational Qualifications Level 4, in management, and Level 3, in care. The manager had applied, to the Commission for Social Care Inspection, to be the registered manager of the home but the process had not yet been completed. A member of staff said, they were always well supported by the home’s manager. The manager said, 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 23 she and her management team had already made progress with developing some recording systems but she knew there were still more improvements that needed to take place. July 2006 the home had carried out a quality assurance survey, where residents and their relatives could comment about the home and how they would like the service to be improved. The manager had not yet managed to carry out a survey this year but she said a survey would be carried out later this year. Records showed service users and their relative’s views were taken into account, about the running of the home. Every month there were meetings for relatives of service users and staff also had an opportunity to comment on the running of the home, during their six weekly staff meetings. The home had carried out monitoring checks and audits of the service and Risk Assessments had been completed. A number of health and safety records were examined for: fire, Control Of Substances Hazardous to Health, portable appliance tests, water temperatures, accidents and checks to the heating system. Documentation confirmed there were regular monitoring checks and health and safety work carried out. The fire brigade, during their last visit, had identified extra fire precautions were required, by means of needing smoke seals on all fire doors. At the time of the inspection ‘site’ visit, the seals had not been fitted. A senior manager, from Redcar & Cleveland Borough Council, informed us the fire door seals were fitted 3 October 2007. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 4 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 3 x 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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. 2. Standard YA2 Regulation 14 15 Requirement Timescale for action 15/11/07 YA6 3. 4. YA17 YA22 17 22 All service users must have an assessment of needs, before they are admitted to the home. Care Plans and Risk Assessments 30/12/07 must be regularly reviewed, so that the home keeps an up to date record of service users needs. The home must keep a record of 15/11/07 all the food provided to service users at the home. The must ensure the Complaints 30/11/07 Procedure is reviewed and updated, so that service users and their relatives have all of the correct information about how to make a complaint. (Previous timescale of 30/12/06 not met) Maintenance work to the home environment, must be carried out for: Unit B • The lounge carpet, near the outside door, that was worn and stained must be replaced • The stained hall carpet 30/11/07 5. YA24 23 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 26 must be cleaned Unit C: • Stained kitchen wall must be cleaned • The grubby extractor, above the cooker, must be cleaned • Kitchen unit doors and drawers, that were chipped and badly fitting, must be replaced • The lounge, with peeling wall-paper, must be redecorated • The toilet wall must be, at least, repaired and redecorated (Previous timescale, for the toilet, of 30/12/06 not met) 6. YA34 17 Staff records must contain: • A recent photograph • Copies of passports and birth certificates • History of employment. (Previous timescale of 30/12/06 not met) 7. YA37 9 The proposed manager must satisfy the requirements of the registered manager and complete the necessary process with the Commission for Social Care Inspection. (Previous timescale of 30/12/06 not met) 30/12/07 30/12/07 17 Jervaulx Road DS0000031330.V351079.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. 3. Refer to Standard YA23 YA36 YA39 Good Practice Recommendations Staff training, for safeguarding vulnerable adults should be updated, so that staff keep an awareness of the procedures. Staff’s one to one supervision should take place at least six times yearly. The home should maintain a system, to regularly review the quality of care provided for service users. From the review, a report must be written to inform what measures are to be taken, to improve the quality and delivery of the service. 17 Jervaulx Road DS0000031330.V351079.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 17 Jervaulx Road DS0000031330.V351079.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!