Inspection on 03/11/06 for 22 Millcroft

This inspection was carried out on 3rd November 2006.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

22 Millcroft 20/11/07

22 Millcroft 03/02/06

22 Millcroft 09/08/05

22 Millcroft 14/02/05

22 Millcroft 21/09/04

22 Millcroft 19/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 22 Millcroft Warley Road Scunthorpe North Lincolnshire DN16 1QL Lead Inspector Ms Matun Wawryk Unannounced Inspection 3rd November 2006 09:00 DS0000002873.V308600.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 DS0000002873.V308600.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. DS0000002873.V308600.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 22 Millcroft Address Warley Road Scunthorpe North Lincolnshire DN16 1QL 01724 282720 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) kirsty.neal@new-era.org.uk www.dimensions-uk.org Dimensions (UK) Ltd Kirsty Anne Neal Care Home 6 Category(ies) of Learning disability (6), Physical disability (3) registration, with number of places DS0000002873.V308600.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 2006 Brief Description of the Service: 22 Millcroft is a care home providing personal care and accommodation for six adults aged 18-65 years with learning disabilities. Three of these places are for service users who also have a physical disability. It is owned Dimensions (UK) Ltd and is situated close to two other homes owned by that Company. The home is located in a residential area close to the centre of Scunthorpe. It is close to local shops, amenities and public transport. The home has its own transport. The home is a purpose built bungalow. All bedrooms are single and have wash hand basins fitted. Bedrooms are decorated and furnished to meet individual service user requirements and preferences. Communal areas of the home are decorated and furnished in a domestic style. Aids and adaptations have been provided as required to meet service users needs. All the service users living in the home are female. Information on fees can be obtained from the manager of the home. Information on the service is made available to prospective and current service users via the statement of purpose, service user guide and inspection reports, copies of these documents can be obtained from the manager. DS0000002873.V308600.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first key inspection of 2006/07. The inspection visit took place over 1 day in November 2006. Mrs Matun Wawryk, Regulation Inspector carried out the site visit. Prior to visiting the home the inspector sent out a selection of survey questionnaires to all the service users and staff and some professional staff. Comments received were analysed on their return and any issues identified were checked out during the inspection visit. Some of the comments received by people have been included in the report. Information received by the Commission since the last inspection was also considered in forming a judgement about the overall standards of care provided by the home. Four service users were at home on the day of the inspection visit. Most of the service users had very limited verbal communication skills; therefore the inspector spent time with service users observing activities instead of conducting formal interviews. The inspector also had discussions with two support workers who were working in the home at the time of the visit. The inspector was unable to speak to the manager because she was on annual leave at the time of the visit. The inspector checked to see that service users privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured service users were safe and protected in their environments. Documentation in relation to the assessments people had prior to admission to the home and support plans produced to meet assessed needs were examined. In addition the inspector also looked at a number of records in relation to medication practices, complaints management, staffing levels, staff training, induction and supervision. The inspector also looked at how the home monitored the quality of the service it provided and how the home was managed overall. What the service does well: Individual support plans for service users were found to be comprehensive and reflected all areas of identified needs. This means staff had access to all necessary guidance to enable them to meet the needs of service users. Service users had good access to professional medical staff and were able to access external services such as dentists and opticians. DS0000002873.V308600.R01.S.doc Version 5.2 Page 6 There remains a core group of staff that had worked in the home for several years. This means service users generally receive care and support from staff they are familiar with. Staff spoken to commented on the approachability of the current manager. All stated they found her to be friendly and efficient, which has contributed to good staff moral. What has improved since the last inspection? What they could do better: Individual support plans were in place for service users and these set out the health and personal care needs identified for each person. Work now needs to be completed on developing the support plans and risk assessments in more suitable formats as one means of further improving the accessibility of these important documents for service users. Some staff in their surveys said more staff was needed. The inspector was not able to find out how staffing levels had been calculated. The inspector advises that a review of staffing based on assessment of the dependency levels of service users should be carried out using a formal dependency tool. This will enable informed judgements to be made about the number of care hours needed to meet the needs of service users. Service users are provided with a warm and comfortable environment, however some carpets need replacing and work needs to be carried out in the garden to improve its accessibility for service users. The home needs to put in place a better quality monitoring system. This is needed to make sure that everyone is consulted about the running of the home and to ensure continuous improvements are made. The home then needs to produce an annual report and make this available to people who use the service, their relatives and carers and other relevant people, including the Commission for Social Care Inspection. DS0000002873.V308600.R01.S.doc Version 5.2 Page 7 The inspector would like to thank everyone who completed a questionnaire and/or took the time to talk to her during this inspection. Your comments and input have been a valuable source of information, which has helped create this report. 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. DS0000002873.V308600.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000002873.V308600.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives have access to sufficient information to help them decide if the home is right for them. The admission procedure was thorough thereby providing staff with sufficient guidance to ensure prospective service users needs are properly assessed and planned for. EVIDENCE: There have been no new admissions to the home in the last four years. The home currently has two vacancies. Assessment of this outcome group was based on available records and relevant policies and procedures. A statement of purpose and service user guide was available. The service user guide had been reproduced using symbols to improve its accessibility for service users. The admission procedure was adequate to guide staff on the actions to be taken to ensure that prospective service users needs are properly assessed DS0000002873.V308600.R01.S.doc Version 5.2 Page 10 and planned for. Evidence from records indicates the care plans and needs assessments for prospective service users are obtained from the relevant placing authorities. During the visit the inspector spoke to the two support workers who were working in the home at the time of the visit, both workers were very knowledgeable about the care and support needs of the service users and were able to fully describe their care needs and routines for the way care should be given. None of the service users were able to tell the inspector about their care needs and the input they required from staff. Three professional surveys were returned; all respondents stated they considered the level of care provided was good. DS0000002873.V308600.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6. 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care and support each service user needs and receives was documented and care provided was based on assessment of individual needs and choices. EVIDENCE: Case tracking took place for two service users. The methodology used was a physical examination of care plans, written surveys to service users, staff, and some health and social care professionals, and direct observation on the day of the inspection visit. DS0000002873.V308600.R01.S.doc Version 5.2 Page 12 The home had made significant progress in developing essential life plans for the service users. Two of the plans examined were found to be very detailed and person centred. Individual support plans were in place for the two service users selected for case tracking and these set out the health and personal care needs identified for each person. Plans looked at had been regularly evaluated and any changes to the care being given was documented and implemented by the staff. There were risk assessment tools for mobility, tissue viability, bed rail provision, medication, nutrition and general issues; all high risk areas identified had been reviewed and care plans were in place to support appropriate care provision. Work now needs to be completed on developing the support plans and risk assessments in more suitable formats as one means of further improving the accessibility of these important documents for service users. Records evidenced regular care reviews were held with the responsible funding authority. DS0000002873.V308600.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to maintain links within the community. The routines of the home are flexible to meet individual service users needs. The meals provided to service users are of good quality and offer variety and choice. EVIDENCE: The home does not employ an activity coordinator; support workers are responsible for organising and arranging activity programmes. Records did not evidence that staff had been provided with training in planning and delivering activity programmes for people with complex needs. The inspector advises that DS0000002873.V308600.R01.S.doc Version 5.2 Page 14 consideration should be given to providing staff with relevant training in this area. A formal activity programme was not available; staff reported that activities were planned on an individual basis. This included; hands massages and nail care, outings, pub visits and shopping trips. Although support plans for recreational and personal development were in place, in some cases these needed to be more detailed to better reflect recreational and personal development needs of the individual. More detailed support plans must now be developed linked to assessments of social needs. The registered person must, on a regular basis, continue to consult service users about the programme of activities on offer in the home and ensure support plans reflect the individual preferences and capabilities of service users. Two out of the four service users who were living in the home at the time of the visit attended day services provided by the local authority. Although staff indicated this was at a very reduced level. As indicated in previous inspection reports anecdotal evidence indicated most service users have had their day centre time reduced over the last few years. This matter needs to be kept under review to ensure service users social, recreational and personal development needs continue to be met in an appropriate manner. Discussion with staff indicated most service users had good contact with their families and friends. Staff stated relatives and visitors are made welcome at any reasonable time and comments received form three relatives confirmed this. Key workers helped service users to maintain family contact by sending cards at significant occasions such as birthdays and Christmas, thereby helping service users to maintain family contacts. The standard of the meal provision in the home was good. Service users were provided with three meals a day and records showed that a varied menu was available. Food likes and dislikes were recorded. The inspector spent time in the dining area observing the lunchtime meal. Staff were observed to assist service users to eat in a sensitive manner and service users were not hurried. Staff had a good knowledge of the service users food preferences, portion size and manner of eating. DS0000002873.V308600.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is offered in such a way as to promote and protect the service users privacy and dignity. Arrangements for meeting the health care needs of service users are satisfactory. EVIDENCE: All the bedrooms are single occupation this means treatments and examinations can be carried out in private. Individual service user support plans describe how personal care should be provided to ensure the dignity and privacy of the service user is maintained and promoted All service users were registered with a GP. A record of routine eye tests, dental and chiropody checks had been maintained and service user weights were being monitored, although not always at frequencies detailed in the service users individual plan. The manager should ensure this now happens. DS0000002873.V308600.R01.S.doc Version 5.2 Page 16 Individual health action plans had not been introduced into the home. The inspector was not able to establish how this matter is going to be addressed because the manager was on annual leave at the time of the inspection visit. Similarly the inspector was not able to establish whether the registered person had ensured (with the agreement of the service user or their representative) an annual health check including a review of medication checks had been requested. These issues will be followed up at the next visit. The home uses the Nomad system for drug administration. Management of medication systems in the home was satisfactory. None of the service users living in the home at the time inspection visit had been prescribed controlled medication. Medication records were checked for three service users as part of the case tracking process: transcribing records were correct with the medication records corresponding to the printed label on the medication. There were no signature gaps on the records. Medication storage in the home is very limited; staff should monitor the temperatures in these areas to ensure they do not exceed the manufacturers guidelines. Since the last inspection a programme of in-house medication training had been introduced and this included assessment of competence. DS0000002873.V308600.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a satisfactory complaints system and staff and service users can be assured complaints and concerns will be listened to and acted upon. Adult protection systems need to be supported by a staff-training programme. EVIDENCE: There have been no complaints made to the Commission or the home in the last twelve months. The home had a clear complaints procedure and the procedure was available in a suitable format for service users. Staff spoken said they had no complaints about the home and felt confident to raise issues of concern if they arose. None of the residents were able to confirm to the inspector their understanding of the complaints process, comments from returned professional questionnaires indicates that professional staff are aware of how to complaint. No adult protection referrals had been made since the last inspection. A procedure for responding to allegations of abuse was available, which reflected the multi-agency procedures in respect of referral and investigation. Records indicated that not all staff had had adult protection training. The need to DS0000002873.V308600.R01.S.doc Version 5.2 Page 18 ensure all staff are provided with adult protection training remains an outstanding requirement from previous inspections and action must now be taken to address this. DS0000002873.V308600.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with a warm and comfortable environment, however some carpets need replacing and work needs to be carried out in the garden to improve its accessibility for service users. EVIDENCE: A tour of the home was carried out and all areas were seen to be clean, tidy and odour free. Since the last inspection the lounge cum dinning room had been redecorated. All bedrooms looked at were clean and tidy and were furnished and decorated in a homely style. Many people had furnished their bedrooms with a range of DS0000002873.V308600.R01.S.doc Version 5.2 Page 20 personal items, some bringing in items of furniture to reflect their own individual choice and taste. Observation of the premises showed that there are some minor areas still needing work; the lounge carpets and some service users bedroom carpets need replacing. Cleaning had failed to remove marks and stains. Whilst these matters do not pose any health and safety problems they do not ensure service users live in an attractive environment. The gardens remain largely inaccessible to service users due to problems with layout and design. This matter has been identified in inspection reports spanning the last fours years. During this time little or no work has been carried out to improve the attractiveness and accessibility of the garden. This means service users do not have free access to all parts of their home. Action must be taken to address this. Staff reported that they had access to all required specialist equipment needed to ensure service users needs could be met, this included a hoist, additional moving and handling and specialist bathing equipment. DS0000002873.V308600.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home generally provides sufficient numbers of staff on each shift to meet the care needs of service users; although a formal review of staff needs should be undertaken when vacancies are filled to ensure staffing reflects the dependency needs of service users. Staff are trained and competent to carry out their duties and responsibilities EVIDENCE: The roles and responsibilities of staff are clearly defined and understood. Two support workers spoken to were able to fully describe the management and reporting arrangements in place in the home. DS0000002873.V308600.R01.S.doc Version 5.2 Page 22 Four service users were living in the home at the time of the inspection. There were two vacancies. Two support workers are normally on duty at anyone time. At night there is one waking and one sleep in worker on duty. Staff spoken to said staffing levels were generally although commented that on accessions more staff were needed. Staff said they were generally able to spend quality time with the service users. Five staff returned a questionnaire of these one indicated staffing levels were satisfactory, the other four said more staff was needed. A formal review of staffing based on assessment of the dependency levels of service users had not been carried out and the home did not have a formal dependency tool. Feedback from staff indicated that the dependency levels of some service users had increased over the years and anecdotal evidence indicates that day centre time for most service users has been reduced. The inspector advises that a formal review of staffing should be carried out using a recognised dependency tool, this will enable more informed judgements to be made about the number of care hours needed to meet the needs of service users. The inspector was not able to check recruitment records for newly appointed staff because the manager was on annual leave at the time of the inspection visit and staff on duty did not have access to these records. This matter will be checked at the next inspection. Previous inspection finding indicates the home follows good recruitment and selection practice. The inspector was not able to establish how many staff had completed or were enrolled to complete an NVQ, because of the manager annual leave. Staff spoken said staff were encouraged and supported to gain appropriate NVQ qualifications. The registered person must continue with the NVQ training programme to ensure 50 of care workers achieve an NVQ if not already achieved. A formal staff supervision programme was in place and records evidenced staff received formal recorded supervision. The inspector was not able to formally examined the staff supervision programme. Staff spoken said they were provided with formal and regular supervision. Staff said that a programme of annual appraisals was in place. DS0000002873.V308600.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was effectively managed. Efforts must now be made to formalise the quality assurance programme. EVIDENCE: The manager has considerable experience of managing the home. Staff spoken to and those who returned a questionnaire said the home was run in the best interests of service users. Staff confirmed that moral was good and staff said there was a good team approach to care delivery at the home. DS0000002873.V308600.R01.S.doc Version 5.2 Page 24 Evidence from staff interviews and staff surveys indicated the staff consider the manager to be approachable, staff said she takes issues raised seriously and takes prompt action to resolve matters. Five staff surveys were returned. All the respondents stated that they felt the home was well managed and that supervisory arrangements were satisfactory. The home had a range of mechanisms in place to monitor the quality of services provided including regular audits of the homes environment, regulation 26 visits and reports, a staff survey questionnaire and individual service user reviews. There was no evidence to show that a specific development plan for the home and published report was available. The registered person must implement a quality assurance programme, which fully meets the requirements of NMS 39. This is needed to make sure that everyone is consulted about the running of the home and to ensure continuous improvements are made. This remains an outstanding requirement from previous inspections and action must now be taken to address this. The home had a range of policies and procedures for health and safety. Safe working practices were maintained by the provision of training to staff in the form of moving and handling, basic food hygiene, first aid and health and safety. The provider information questionnaire states current certificates were in place for the gas, portable electrical appliances and fixed electrical systems. Accident records were completed appropriately and the manager carried out regular audit on these to help spot any problems or recurring themes. DS0000002873.V308600.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 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 2 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 3 36 3 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 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 3 X DS0000002873.V308600.R01.S.doc Version 5.2 Page 26 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 YA28 Regulation 23(2o) Requirement The registered person must ensure that the gardens are safe, well maintained and accessible to all service users. (Timescale of 16.10.03 not met 31.11.05 and 31.3.06 not met). Timescale for action 31/03/07 2. YA39 31/01/07 24(1ab)(2&3) The registered person must develop a quality assurance and monitoring system that meets the requirements of this standard and produce an annual development plan based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. (Timescale of 19.2.04, 31.12.05 and 30.4.06 not met). 12(3) The responsible person must develop support plans in a more accessible format for service users. (Timescale of 31.3.05, 31.11.05 and 31/03/06 not met). 31/03/07 3. YA6 4. YA26 16 The registered person must 31/01/07 have two bedroom carpets and DS0000002873.V308600.R01.S.doc Version 5.2 Page 27 the sitting room carpet replaced 5. YA12 6 The registered person must continue to consult with service users and or their representatives on a regular basis to ensure service users benefit from activity programmes, which reflect the service users individual needs, preferences and capacities. Service users must be provided with a programme of valued and meaningful activities. Timescale 30.4.06 not met The registered person must ensure (with the agreement of the service user or their representative) an annual health check including a review of medication is requested 31/01/07 6. YA19 13(1) 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA33 Good Practice Recommendations The registered person should develop a tool to assess the dependency levels to inform decision regarding staffing levels. The registered person must provide all staff with equal opportunities training, including disability training; race equality and anti-racism. The registered person should ensure that training is ongoing so that 50 of care staff in the home hold NVQ 2 DS0000002873.V308600.R01.S.doc Version 5.2 Page 28 2. YA35 3. YA32 3 YA20 Medicines must be stored at the appropriate temperature. A record of temperature must be maintained for all areas where medicines are kept DS0000002873.V308600.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000002873.V308600.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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