Inspection on 05/10/06 for 204 Ashby Road

This inspection was carried out on 5th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

204 Ashby Road 19/03/08

204 Ashby Road 04/07/07

204 Ashby Road 31/01/06

204 Ashby Road 30/06/05

204 Ashby Road 26/02/05

204 Ashby Road 07/07/04

204 Ashby Road 20/11/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 204 Ashby Road, Burton On Trent Staffordshire DE15 0LA Lead Inspector Ms Wendy Jones Key Unannounced Inspection 5 & 9 October 2006 12:30 204 Ashby Road, DS0000004912.V299578.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 204 Ashby Road, DS0000004912.V299578.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. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 204 Ashby Road, Address Burton On Trent Staffordshire DE15 0LA 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) 01283 538445 Robinia Care Homes (2) Limited Carol Walton Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 Brief Description of the Service: Number 204 Ashby Rd is registered for six younger adults with a learning disability. The building is a large period semi-detached house located in a residential area, on the outskirts of Burton upon Trent. The other half of the semi-detached property is privately owned. The home is conveniently situated close to a town, on a bus route and close to shops and all amenities. The house is set back from the main road and has tarmac drives and adequate parking space. The building is on four floors (including basement) and comprises six bedrooms, an office, lounge, dining/activity room, kitchen/dining room, art room, two bathrooms each with bath, shower and toilet, two separate toilets, laundry room and storage. The home is not suitable for any person with a severe physical disability. There is a very large garden at the rear and a useful patio area. Suitable outdoor furniture has been provided, including swings. A care manager and a team of support workers provide care. The home has its own multi-seat vehicle, which is extensively used for the service users. A recent additional activities /day service worker has been employed to support service users to access community activities. The core care fees range from approximately £1,346 per week to £1,538, this does not take into account any additional fees, for example there were additional weekly costs of between £476 and £611, the information in the home relating to care costs was not up to date. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection visit of 204 Ashby Road, carried out over a period of two days, from the 5 October 2006. The inspection methodology included pre inspection planning and collection of information; service user and relative questionnaires, feedback from social workers, community nurses and a GP; inspection of the environment; interaction with service users, discussion with staff and the manager; inspection of care records and other documents relevant to the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Information for prospective and current service users must include the current scale of charges and fees for a placement. The service must ensure that service users needs in terms of social, leisure and recreational opportunities and community presence and participation. The staff must ensure that the care plans for service users and the recommendations made by health professionals are followed to ensure the best interests of service users. The deployment of staff must be arranged to ensure that service users are properly supported and supervised and have opportunities access community facilities. Staffing levels must reflect the needs of service users. All staff must attend fire drills at least twice per year. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 6 The service must display a current employers’ liability certificate. A development plan based upon the outcomes of quality audits must be produced and a record of the monthly visits to the home, undertaken on behalf of the provider to evidence the conduct of the service must be made available in the home. 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. 204 Ashby Road, DS0000004912.V299578.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 204 Ashby Road, DS0000004912.V299578.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 The outcome for this standard was good; this judgement was based upon the information available and from discussion with the manager. The service has information about the service aims and objectives, but it wasn’t up to date. EVIDENCE: The service has a statement of purpose that was displayed in the home and provided information regarding the service philosophy aims and objectives. A service user guide was also available in the office and each service user had their own copy in their care files. Action was required to ensure the service user guide for each service user included the fees applicable for the individual and a break down of the cost of the service. The service user guide had been created in a user-friendly format, for the benefit of service users. Since the last inspection there have been no new admissions to the home. One service user had been discharged and moved to a more suitable service. The organisation has revised its’ admission procedures since that time, to ensure that any prospective service users needs can be met. Assessments were included in the individual care records; they gave an account of the needs of the individual. Due to limitations relating to communication and capacity of service users it was difficult to ascertain the individuals wishes. Care assessments had bee carried out on their behalf by 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 9 social workers in co-operation with families and carers and information was provided from previous placement if applicable. 204 Ashby Road, DS0000004912.V299578.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9. The outcome for these standards was adequate; this judgement was based upon the information available in care records; from discussion and observation. The quality of care planning and care information varied, the service must ensure that care plans are easily accessible to staff in a format that can be easily understood. EVIDENCE: The service is in the process of transferring to a person centred plan approach of care. At the time of the inspection this was very much a work in progress. The aim was to create a health action plan for each service user, (this work had been undertaken), a file for financial matters (also completed), a file for care and personal record, which had yet to be fully implemented. The current care files were felt to be cumbersome and not user friendly. In one example the care file included a comprehensive 24-hour plan of care that detailed the individuals preferred routine and the assistance he/she required. It also identified particular areas of need and the level of support to be provided. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 11 In another example the information was less comprehensive and did not provide a detailed account of the individuals needs or preferences. The manager stated that the work was on going. It appeared from discussion with the care manager that she had undertaken to take sole responsibility for the development of the new person centre planning and while accepting that she had responsibility for ensure that the care records accurately reflected the needs of service users it was also felt that other staff must be involved in the implementation of the care plans. There had been some concern expressed by other professionals that the care plans of service users were not always followed consistently, this was discussed with the manager who identified that there had been a difficulty which had been addressed and that staff were all now aware of the importance of consistency in following agreed care plans for the benefit of service users. During the visit a review of a service user was arranged with her consultant and community nurse to discuss further methods of improving her quality of life and safety. Additional psychological input was provided to support the service user this service was arranged by the organisation. It was understood that a review of the current behavioural management strategies for this service user would be undertaken to ensure that they reflected the changing needs identified. An interview with support worker showed that he had a good knowledge of the care needs of service users; he gave examples of appropriate intervention relating to the management of challenging behaviour. Financial records for service users were assessed during this visit, the records included evidence of any deposits or transactions made on behalf of service user and the evidence of what the money had been spent on, there were receipts in place to evidence this. Following the assessment of the records the manager was informed that an inaccuracy had been found that had not identified by staff. The procedure indicates that staff should check the service user monies against the record of money at each handover, there had been a discrepancy for approximately 4 day’s indicating that the procedures had not been properly checked. While the amount was not significant, it is important that all staff are reminded of the importance of accuracy. 204 Ashby Road, DS0000004912.V299578.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 ,17 The outcome for these standards was poor. This judgement was based upon the information provided from care records; from observation during the inspection and from discussion with staff. Service users opportunities to access community activities were limited, due to staffing constraints and service users were observed to spend long periods of time passively engaged in activities in the home. EVIDENCE: Service users were involved in some activities during the daytime hours. One service user accessed a special day service from Monday to Friday. Others relied on the activities that were provided in the on-site activities/art room and those provided by the staff team. From observation there were poor levels of engagement in the in home activities for service users. From a record of activities for a month, 2 service users were involved in: 25 and 3 sessions of involvement in domestic chores. 20 and 0 sessions of listening to music. 15 and 18 watching TV. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 13 5 and 2 drives out in the car. 13 and 0 sessions playing with a jigsaw. 9 and 0 sessions dancing, while listening to music 4 and 3 sessions in the garden 15 and 0 in room playing with toy’s 5 and 0 looking at books. Interactive sessions included. 17 and 3 sensory sessions 3 and 0 horse riding 1 and 0 manicure 1 and 0 baking 2 and 1 bowling 3 and 0 rambling 5 and 0 art room The service had provided a support worker who was deployed during peak times during the day to support service users to access community activities. This position was reported to have improved service users opportunities to access community activities. One service user had a bicycle that he was reported to enjoy riding; this was also identified in his last review. The manager stated that due to the constraints of staffing he had not been able to go out on his bike very often citing 3 times this year. Clearly if this activity is identified further efforts should be made to ensure he has the opportunity enjoy this activity more frequently. A support worker stated that some limitations to community access was due to a lack of car drivers and in the evening due to the needs of a service user who presented with challenging behaviour. There were also concerns that some service users isolated themselves because of the behaviour of others. At least three service users were reported to dislike a noisy environment and would avoid interactions with others. This also extended to mealtimes where two sittings were now arranged to ensure service users were able to eat their meal without too many distractions of problems. During this visit 3 staff were deployed during the evening shift, one provided 1:1 support for a service user, one had taken responsibility for cooking the evening meal and the third was responsible for supporting the other four service users and administering medication. It is recommended that staff deployment at this time be increased for the benefit of service users. Service users had been supported on holidays or short breaks. It is understood that as part of the contract price the organisation contributes £500 toward the cost of a holiday. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 14 Meals were planned with, or in the best interests of service users based upon know preferences. The service had supplied a picture reference system to enable service users to identify what the meal of the day was. This system was used through out the kitchen to also identify cupboard contents. Service users had free access to the kitchen and were observed requesting drinks or snacks throughout the day. Each service user had a record of the meals they had eaten in their care files, and although the menus didn’t show a choice of main meal at every mealtime there was evidence of service users making a different choice to the one offered. Fridge and freezer temperatures were recorded daily. And food was appropriately stored. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 The outcome for these standards was adequate. This judgement was based upon information provided in care records, from pre inspection information and from discussion. The personal care needs of service user were met; issues relating to staff consistency when addressing challenging behaviour were raised. EVIDENCE: At the time of the visit the home was occupied with 5 service users, with 1 vacancy. Dependency levels in the home are high with all service users requiring some degree of support with personal care. Service users have some difficulties communicating effectively; at least 1 service user does not verbalise. The service provides a picture reference method of communication and Makaton a form of sign language. Each service user can exhibit difficult to manage behaviour, which can be described as challenging; this behaviour can at times have an impact on other service users. Service user personal care needs were satisfactorily met. Staff were observed to knock on service users bedrooms doors before entering and discussing care needs with individuals. Each service user has key and co-workers. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 16 Care plans showed the personal and health care needs of service users and the action required to meet the needs. The service has started to introduce Health Action plans for each service user. These detailed the assessed health needs and the action to be taken to meet their needs. Records included health related appointments such as GP, chiropody and dental care. Feedback from a GP practice gave negative comments regarding the contact it had with the home citing poor levels of communication. Another health professional identified concerns about communication and staff not following care plans. These matters were discussed with the manager who identified that problems had occurred but that the service was now working to resolve the matters in cooperation with the health professionals. The contracted clinical psychology service “Denzie” practice, provide regular support and advice to all the Robinia Care services, and undertake assessments relating to behavioural concerns. The frequency of their input is dependent on the level of need, although it was understood that this service is included in the additional fee costs for all service users. From observation and from discussion it was of concern that the behaviour of one service user appeared to have an impact on the lifestyles of other service users. It was also of concern that in the behavioural management assessment it was recorded that the challenging behaviour were not detrimental to others. This did not appear to be the case as staff identified that some service users lifestyle were affected by challenging behaviour of other service users. It was suggested that this is discussed and any inaccuracies resolved for the benefit of all service users. In another example, triggers for challenging behaviour were identified by staff as the weather or specifically for a service user. This wasn’t mentioned in the behavioural management assessment. The care manager felt that it wasn’t necessarily the case, but again some clarity should be sought to ensure that any assessments and strategies to address assessed needs are accurate. Medication was suitably stored in a lockable facility. The service operated a monitored dosage system for the administration of medication. It was reported that staff responsible for the administration of medication had received certificated training and others were to receive the training. Issues arose related to the storage of Temazepam medication and a requirement was made that it should be stored as a controlled drug. The service has adopted a procedure that requires two staff to sign the medication records at the time of administration this change to the procedure followed an issue of maladministration that occurred earlier this year. Appropriate action had been taken to address the matter at the time of the incident. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The outcome for this standard was good. This judgement is based upon discussion and from information in records. The complaints procedure provided information for service users, relatives and others to make their concerns known. The service has demonstrated that Vulnerable adults issues are managed properly and action taken where necessary to safe guard service users. EVIDENCE: The service has a complaints procedure that has been reproduced in a userfriendly version for service users. Complaints records showed that there had been some issues raised by the neighbours of the home. There was evidence that the service and the management of the organisation had acted appropriately and responsibly to resolve the matters to the satisfaction of the complainant and in the best interests of the service user. One outstanding complaint was being dealt with by the organisation. At the last inspection a vulnerable adults referral had been made and investigation carried out, (the issue had not occurred in the home). The interim recommendations from that strategy meeting had a significant impact on the lifestyle of the service user, and it was of concern that the matter had not been resolved. A further review of the needs of the service user was arranged for the following month. It was suggested that the care manager asked that the matter be concluded fro the benefit of the service user. In a separate reported incident there had been allegations that a member of staff had used inappropriate physical intervention techniques. Immediate action had been taken to safeguard service users and the matter investigated. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 18 The evidence from the records available prior to and during this inspection showed that all staff had attended training in the protection of vulnerable adults and recognising and reporting abuse, or had training planned. The organisation has a satisfactory policy and procedures for staff to follow in the event of suspected abuse. All new staff had received instruction and guidance in this subject at induction. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 and 30 The outcome for this standard is good. This judgement was based upon the information available, inspection of the environment, observations and discussion. The property provides sufficient communal and personal space for service users and is generally well maintained. EVIDENCE: The home is a large semi detached property in a residential area of Burton on Trent, located on a busy main road. The home has a main front entrance where the visitors’ book was located. It would beneficial for a doorbell to be provided at the front door. A side entrance leads into a small fenced area and provides some security for service users once they leave the home. Staff and service users mainly use this entrance. The home includes a basement level where a sensory room an activities room, a laundry and a medical room have been created. The activity and sensory room are on occasions used by the organisation’s activities co-ordinator to provide a service for service users at 204 Ashby Road and from other homes within the company. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 20 There was evidence of what appeared to be damp in one area of the basement where wallpaper was peeling off the wall. The manager stated that there were plans for this area to be refurbished in the next financial year. On the ground floor the home has a large entrance hall, with a pleasant lounge, lounge/dining room and kitchen/dining room leading off it. The office has also been moved to this floor from the basement since the last inspection. The kitchen is due to be refurbished but is serviceable clean and spacious. The first floor is on two levels and provides five bedrooms, all were single rooms, and none had an en-suite. The service’s main bathroom and separate WC are located on this floor. The main bathroom was locked during the day to prevent a service user flooding it; there was evidence of flood damage to the ground floor ceiling. They would both benefit from some homely touches. The second floor has an en-suite bedroom. A sample of 3 bedrooms was seen during this visit with the co-operation of the service users. One did not have any window dressing at all and another had some staining on the carpet. There was evidence that service users had been supported to personalise their rooms and evidence of some suitable furnishing. Since the last inspection improvements to some bedrooms have been made, for example new carpets and redecoration. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. The outcome for this standard was adequate. This judgement was based upon information provided from discussion, records and observation. The deployment of staff must be revised in the best interests of service users. The frequency of staff supervision must be increased. EVIDENCE: Staffing levels were confirmed from the inspection visit and the staff rota as a minimum of 3 throughout the waking day and 2 at night. The care manager’s hours were reported to be supernumerary, but at the time of the inspection she had assisted with a night shift and was providing some day shift hours. This situation had arisen due to staff vacancies, the manager stated that recruitment was underway to fill the vacancies and 4 new care staff would be joining the team. Since the last inspection the service has recruited an activities support worker who’s role is to provide additional hours to support service users when on planned or unplanned activities outside of the home, unfortunately during the inspection this person was on annual leave and her hours had not been replaced. The needs of service users were quite high at this home, and the inspector was concerned about the numbers of staff deployed during the evening shift, particularly during the tea time period. This was observed to be a quite difficult 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 22 time, with 1 staff preparing and cooking the evening meal, another providing 1:1 support and the other to undertake medication administration and to support all other service users. It was advised that the care manager must reconsider the deployment of staff at this time. A number of service users had funding at 1:1 for periods throughout the waking day. 4 were funded for 2 hours per day 1:1 and 1 for 10 hours per day. It was a requirement that the staffing hours are reviewed to ensure that all service users receive the level of support they are funded to receive. The numbers of NVQ trained staff did not meet the minimum standards required, 4 staff of the 16 staff had the qualification, the deputy manager stated that 3 staff were undertaking the training. Records showed that most of the staff were up to date with mandatory training or had training planned. The use of a training matrix gave a visual reminder to the manager and staff, when training was due or should be scheduled. Discussions with a support worker confirmed that mandatory training was up to date. Staff meeting were planned regularly the standard being monthly, records of recent meetings were provided for inspection purposes. The deputy manager confirmed that she had been allocated responsibility for some staff supervision. It was confirmed at this inspection if staff supervision was taking place on a regular basis the service must ensure that staff supervision is carried out at least 6 times per year. Samples of staff recruitment files were checked during this visit, the majority of the information required by regulation including 2 written references, application forms, Criminal Records Bureau checks and protection of Vulnerable Adults checks, evidence of training and induction, photographs of staff must also be provided. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 The outcome for this standard was adequate. This judgement was based upon information provided and from discussion. EVIDENCE: Records showed that a fire safety risk assessment had been reviewed on 15 /06/06, daily fire panel checks were undertaken and records relating to other fire safety checks were maintained. Records of evacuation/drills at the home showed they had occurred on 4 occasions this year, but that not all staff had been involved in fire drills. Regulation 26 reports were available in the home up until 27/06/06. The employers’ liability insurance certificate for the service was out of date. The manager stated the updated version had been returned due to an error. Quality assurance questionnaires had been sent out to service users and others to ascertain views on the service. A number had been received in June and July. Some comments were negative, but there did not appear to be any 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 24 evidence that the service had taken action to deal with them or to develop an action plan. The manager was reminded that the service must demonstrate how it intends to develop the service and address any of the matters raised. 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 2 26 X 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 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 2 2 2 X LIFESTYLES Standard No Score 11 X 12 1 13 2 14 2 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 3 3 2 X 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 26 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 YA33 Regulation 18 Requirement The registered person must ensure that staffing levels are sufficient at all times. (Previous timescale 14/03/06) The service user guide must include the current rate of fees charged, including any additional fees and a breakdown of how those costs are calculated. Reports of the monthly visit to the home by a representative of the registered person must be available in the home. The registered person must ensure that all medication is appropriately stored. This relates to the Temazepam medication. All staff must be involved in fire drills and receive fire training. (Previous timescale31/03/06) The registered person must ensure that procedures relating to the safety of service user monies are followed. Agreed protocols for the administration of as-required DS0000004912.V299578.R01.S.doc Timescale for action 09/11/06 2 YA1 5 09/11/06 3 YA39 26 09/11/06 4 YA20 13 10/10/06 5. YA42 23 09/11/06 6. YA7 12 10/10/06 7. YA20 13 09/11/06 204 Ashby Road, Version 5.2 Page 27 medication must be in place. (Previous time scale 31/03/06) 8. YA14 16 The registered person must ensure that individual service users are supported to engage in more varied activities both in and out of the home. (Previous time scale 30/04/06) The registered person must provide suitable flooring and window covering in bedrooms. (Previous timescale 31/03/06) The registered person must ensure that the recommendations of health professionals are followed to ensure that the needs of service users are properly met. Staff supervision must be undertaken at least 6 times per year for each member of staff. The registered person must ensure that all recruitment records required are kept in the home i.e. staff photographs. The registered person should produce an action and development plan based upon the outcomes of the quality survey undertaken earlier this year. 09/12/06 9 YA25 16 09/12/06 10 YA17 YA6 12, 13 09/11/06 11 12 YA36 YA34 17 17, schedule 4 24 09/12/06 09/12/06 13 YA39 09/12/06 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. Refer to Standard YA6 YA6 Good Practice Recommendations The service should make further efforts to fully implement a person centred approach to care. The 24-hour plan used as an integral part of the person centred approach to care should give a detailed account of the needs and preferences of the service users. The number of NVQ 2 trained staff should be increased to meet the recommended 50 of the work force. 3. YA32 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 204 Ashby Road, DS0000004912.V299578.R01.S.doc Version 5.2 Page 30 - 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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