Inspection on 12/06/06 for 281 - 287 St Georges Road

This inspection was carried out on 12th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 25 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

281 - 287 St Georges Road 17/03/09

281 - 287 St Georges Road 15/01/07

281 - 287 St Georges Road 24/01/06

281 - 287 St Georges Road 13/09/05

281 - 287 St Georges Road 12/10/04

281 - 287 St Georges Road 28/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 281 - 287 St Georges Road 281, 283, 285, & 287 St Georges Road Hull East Yorkshire HU3 3SW Lead Inspector Christina Bettison and Hilary Sleights Unannounced Inspection 12th June 2006 09:00 DS0000000916.V299624.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 DS0000000916.V299624.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. DS0000000916.V299624.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 281 - 287 St Georges Road Address 281, 283, 285, & 287 St Georges Road Hull East Yorkshire HU3 3SW 01482 618096 01482 329337 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) Avocet Trust Position Vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places DS0000000916.V299624.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To retain one service user over 65 years of age. Date of last inspection Brief Description of the Service: The service at 281-287 St Georges Road is managed by Avocet Trust who rent the premises from Sanctuary Housing. It is one of a small number of similar services that Avocet provides. Avocet Trust is a registered charity. 281-287 St Georges Road consists of four separate units registered to provide care for 12 service users. The home is situated just off the Hessle Road shopping area to the west of the city. Two of the units are for 4 service users and two are for 2 service users, all accommodated in single rooms and each house has its own separate garden area. Three houses have a relaxation room and the house without has an additional lounge. Each house also has a communal lounge/dining area, kitchen, laundry and bathroom. One house has an additional bathroom. There are a variety of shops, pubs, GP surgeries and post office all within walking distance. Public transport to various parts of the city is easily accessible and in addition some of the service users have their own car arranged through their mobility benefits. There are parking facilities on-site. Weekly fees range from £856 - £1,000 per person per week. Additional charges are made for the following: newspapers/magazines, hairdressing, chiropody, transport for social activities and sweets. Information on the service is made available to current service users via the statement of purpose, service user guide and inspection report. DS0000000916.V299624.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 1 day in June 2006. Relative surveys were posted out of which 7 were returned; visiting professionals surveys of which 3 were returned and staff surveys of which 6 were returned. During the visit the inspectors spoke to the manager and several staff. The service users that live at St Georges Rd have complicated needs and are not able to tell the inspector of their views therefore in this report comments from relatives, social workers and independent advocates have been used to help to form a view whether service users needs are met or not. Observations of care practice were made to assess service user satisfaction. The inspector looked around the home and looked at some records. Information received by us over the last twelve months was considered in forming a judgement. Prior to the visit the inspector referred to notifications sent to the Commission for Social Care Inspection, the event history for the home over the past year and the completed pre- inspection questionnaire. The site visit was led by Regulation Inspector Mrs. C. Bettison who was accompanied by Locum Regulation Inspector Mrs. H. Sleights, the visit lasted eight hours. The CSCI have serious concerns about the standard of care and management at the home will be considering issuing Statutory Requirement Notices if significant improvements are not forthcoming within the next few weeks. What the service does well: Avocet Trust provides accommodation and personal care support and is a good service for adults with a learning disability and other needs. The primary aim is to enable people to develop as much independence as possible, whilst helping them to be more confident and access community facilities. The houses are located in the local community and are on a bus route making all leisure facilities and shops easy to get to. All service users are provided with a single room that is nicely personalised to their own taste, in a house for no more than 4 people thereby providing them with a home and private areas to their liking where they can spend private time or receive visitors. DS0000000916.V299624.R01.S.doc Version 5.2 Page 6 Families are encouraged to be involved as much as they wish to and are made to feel welcome when visiting their relative. What has improved since the last inspection? What they could do better: Each person living at the home should have a detailed individual plan, which guides staff on how their needs must be managed. Important information, e.g. health assessments, risk assessments and behaviour management plans which would help staff and improve the quality of care, is missing. As peoples needs change the plan should change and it should be regularly reviewed however this has not happened. This means that service users needs may not be met. The manager must make sure that staff meet the complicated health needs of service users and special health advice is followed. Service users must be helped to identify and meet their health care needs. The manager must ensure that medication is handled appropriately, service users must receive their medication when they need it and accurate records must be kept, if this does not happen service users may placed at risk of harm. Each member of staff at the home should have a regular meeting with the manager to discuss the training they may need, support and other things. This has not been happening as often as it should. DS0000000916.V299624.R01.S.doc Version 5.2 Page 7 At the time of the inspection the home had a new manager however she needs to be registered with the CSCI, in order to give service users and staff a sense of stability. The quality monitoring system must be further developed to make sure that everyone is asked about the running of the home and improvements are made. The manager and staff need to make sure that they meet the diverse needs of service users by providing activities that meet the individualised needs of service users. 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. DS0000000916.V299624.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 DS0000000916.V299624.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: There had been no new service users (who would have had their needs assessed) come to stay at St.Georges Rd since the previous inspection; therefore none of these standards were assessed. DS0000000916.V299624.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): 6,7,9 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Service users needs are met on an informal basis by sufficient numbers of staff however the quality of the service user plans and risk assessments are very basic. These shortfalls have the potential to place people at risk and mean that service users assessed needs are not met. EVIDENCE: Individual service user plans are available however they do not reflect the full range of needs and do not ensure that all aspects of health, personal and social care needs are identified and planned for. Three care files were examined as part of the inspection process. The service user plans did not include everything that is detailed in the local authority assessment/care plan and did not detail accurately what staff need to do to meet service users needs. DS0000000916.V299624.R01.S.doc Version 5.2 Page 11 Work had been undertaken in the development of the service user plans and detailed personalised risk assessments however the standard of the documentation was not consistent. The new manager stated that she was well aware that the service user plans all needed attention. She had made a start alongside one of the senior support staff on the plans and one of those seen was excellent however the manager now needs to ensure that all service users have an individual plan of a consistently high standard. The manager stated that she intends to provide training for all of the staff on care planning. Discussion with staff suggested that service users basic care needs were being met even though there was a lack of clear plans and guidance. This approach is dependent on staff memory and good verbal communication systems. Service users are at risk of not having their care needs met if these informal systems break down. Risk assessments were in place for some areas that posed a risk to service users and measures put in place to minimise the risks, e.g. personal safety, access to the kitchen and leisure activities, however the quality of some of the risk assessments continues to be poor and does not ensure the health, welfare and safety of service users and staff. The care file and individual plan in one of the houses that had previously been the subject of a POVA enquiry that was subsequently examined during the monitoring visit in December and had not yet been updated at the inspection on the 24th January 2005 and also again at the follow up visit on the 30th January 2005 had now been updated and gave very clear guidance to staff. A senior support worker from another service had completed this and should be commended for a very thorough piece of work. The protocols are now in place for the management of the service users care/ temperature fluctuations and are written up as part of the individual care plan and the service user has not had recent hospital admissions therefore her health needs in this area are being met. There had been much improvement in the night time monitoring and recordings and the service user had had a care plan review in May 2006. Of the other two care files examined both were lacking in detail, in one of the care files the service users assessments states that there is a risk of him choking when eating this was not documented either in the form of a care plan or risk assessment, there is reference to “walk with …….in the correct manner” but nowhere did it state what the “correct” manner was, the service user clearly needed a lot of assistance with personal care and again this was not referred to in the plan. In the other care file examined this was again lacking in detail and the last care review had taken place on 6/7/05. This particular service user can on occasions display behaviours that can be difficult to manage and specific DS0000000916.V299624.R01.S.doc Version 5.2 Page 12 techniques or methods of communication are required in order to minimise the risks. There was no evidence of a behaviour management strategy or care plan for this area of need. DS0000000916.V299624.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16, and 17 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. A limited range of activities within the home and community mean that not all service users have the opportunity to participate in stimulating and motivating activities that meet their individual needs, wants and aspirations. EVIDENCE: The inspector was informed that none of the service users are engaged in work placements. The inspector was informed that some service users enjoy an active social life, such as bowling, swimming, shopping, visits to the hairdresser, walks and out for meals at the pub, visiting friends, one of the service users support Hull City AFC, however this was not evident in the care files examined and notes from a staff meeting confirmed that the lack of staff meant that service users couldn’t always be supported to go out. DS0000000916.V299624.R01.S.doc Version 5.2 Page 14 Service users are supported to either visit their parents/relatives homes or are visited by them at their home and contact is welcomed. The inspector was informed at the previous inspection that it had been a priority of the previous managers to ensure that service users had access to the community and a varied programme of activities, however there was still little evidence that this is taking place. For three service users care files examined all three service users had not been out of the house for two weeks. If there are reasons why the service user does not go out due to ill health, behaviours or choice this must be clearly documented and/or agreed at a multi agency review meeting. Some service users attend Avocets five senses day service and take part in activities. The inspector was informed that the manager and staff promote a healthy eating menu but try to balance this with service users likes/dislikes and special treats on occasions. Some of the service users had been assessed by the dietician and the home follow the recommendations given, however the inspector was informed that all of the service users in one of the houses are on a liquidised diet and there was little evidence as to how this decision had been reached. A requirement was made at the previous inspection that the service users must be re assessed by either a dietician or speech and language therapist and their guidance and recommendations documented in the individual plan and followed by all staff, this has been completed for one service user and the home is awaiting the speech and language therapist assessments for the others. DS0000000916.V299624.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): 18,19,20 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Service user’s health, personal and social care needs are not being fully met and medication is not being managed appropriately. These shortfalls have the potential to place service users at risk. EVIDENCE: Three service users care files were examined as part of the inspection process. There was some evidence that contact with GP, dentist, optician, audiologist, chiropody, community nurses and therapists and consultants was being facilitated for service users, however record keeping was inconsistent and untidy. Although the community nurse had visited some service users, there was little evidence that any health screening or the development of a health action plan was being progressed. There was little evidence that access to health professionals was being facilitated on a regular basis. DS0000000916.V299624.R01.S.doc Version 5.2 Page 16 The new manager explained to the inspector that one service user had been having some health problems and that the staff had been supporting him to access health provision, there were some decisions to be taken regarding his ongoing health care however the response to holding a best of interest meeting had been slow meaning that service users health needs were not being met. The registered person must ensure that adequate records are kept to evidence that service users health is monitored and potential complications and problems are identified and dealt with at an early stage, including prompt best of interest meetings and referral to an appropriate specialist. The home has policies and procedures for the administration of medication however not all staff have fully completed the training for the administration of medication that includes a competency check or a workbook to complete at the end to ensure staff understand their responsibilities, therefore this remains an outstanding requirement. Medication stored and records were examined as part of the inspection, the inspector found stesolid (rectal diazepam) and an enema that was out of date. Temazepam was not being stored as a controlled drug, there were gaps in signatures on the Medication administration recording sheet and on one occasion a dosage had been changed when being transcribed. The manager needs to ensure that all medication is managed appropriately and that staff are competent. From observations it was apparent that staff promoted service users dignity, privacy and respect. Staff were observed to behave in an appropriate manner towards service users. DS0000000916.V299624.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 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a complaints system and there had been no complaints since the previous inspection. All staff are aware of their responsibilities with respect to POVA however due to the unsatisfactory attention to meeting health needs, poor service user plans, and unsafe medication practices service users are not protected from harm whilst in the care home. EVIDENCE: Neither the home nor the CSCI had received any formal complaints about the home since the previous inspection. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of service users money and financial affairs. The manager and all staff have had Protection Of Vulnerable Adults (POVA) training. The staff on duty displayed a good understanding of the vulnerable adults procedure and they are confident about reporting any concerns and certain that any allegations would be followed up promptly, and the correct action to be taken however the unsatisfactory attention to meeting health needs, poor service user plans, and unsafe medication practices mean that service users are not protected from harm whilst in the care home. DS0000000916.V299624.R01.S.doc Version 5.2 Page 18 DS0000000916.V299624.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): 24,29 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The environment provides surroundings in which to live. service users with comfortable and safe EVIDENCE: 281-287 St Georges Road consists of four separate units registered to provide care for 12 service users. The home is situated just off the Hessle Road shopping area to the west of the city. Houses 285 and 287 are for 4 service users in each house and houses 281 and 283 are for 2 service users in each house, all service users have single rooms that are nicely personalised and each house has its own separate garden area. One of the gardens has recently been upgraded to provide a patio and barbecue area. 287 St Georges rd. DS0000000916.V299624.R01.S.doc Version 5.2 Page 20 From observation and discussion with senior staff it was apparent that some redecoration had taken place. The sensory room, which was not used often, has been decorated and turned into a dining room and one bedroom had been decorated. The lounge and hallway have been redecorated and new carpets fitted. 285 St Georges Rd Three bedrooms have been decorated and new carpets fitted. The hall and lounge would be having new flooring fitted on 16/7/06. 281/283 St Georges rd. The whole of both of these houses had been redecorated and were just waiting the new carpets to be fitted. At the previous inspection a requirement was made that the bath in 281 St Georges Rd requires repair or replacement and consideration should be given to protecting the staff health, safety and well being as they currently have to bend over the bath when assisting service users to bathe, this has not been attended to and remains an outstanding requirement. The kitchens in all of the houses are looking tired and dated and would benefit from replacement or refurbishment. Comments received from relatives included “ when I visit the home is always clean and is a working home. The kitchen is always a hub of activity usually involving the clients. The feeling I get is that it is warm and friendly and I am always made to feel most welcome.” DS0000000916.V299624.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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are cared for by a staff team that are well meaning and caring, all mandatory training is provided and robust recruitment procedures are in place however, little supervision is taking place and there is a lack of planning with regard to training this leads to service users individual specific needs not being adequately met. EVIDENCE: From examination of records, discussion with staff and observation it was evident that staff work to support the written aims and objectives of the home. It was also evident from discussion with staff that they knew how to meet the needs of service users and there was some evidence in care files of the involvement of other agencies with specific expertise. Staff personal files were examined for 3 staff and found to be well organised with all information required by regulation to be found. Robust recruitment is now taking place meaning that service users are protected from harm. The staffing in 287 St Georges Rd has been reviewed and altered. A full time senior support worker has been moved from one of the other bungalows, a full time grade “c” staff appointed and one of the staff has been upgrade to a “b” DS0000000916.V299624.R01.S.doc Version 5.2 Page 22 grade meaning that there is a better balance of grades, skills and competencies within the house to meet service users needs. New staff appointed have received their workbooks and commenced or completed their LDAF induction. The CSCI are aware that Avocet are working towards a solution to ensuring that staff receive appropriate training and that staff are working towards their NVQ level 2. However there are 27 staff at St Georges Rd split up between the four houses, for management purposes there is a full time senior in 2 of the houses, a part time senior in one of the other houses and a “c” grade in the other house. Out of 27 care staff 7 staff have NVQ level 2.The inspector was informed that 4 staff are registered and working towards NVQ level 3 and 9 staff are registered and working towards level 2. The registered person must ensure that 50 of staff are qualified to NVQ level 2. The senior staff will be commencing annual staff reviews and have completed a staff training audit which evidences were there are gaps in staff skills. There was no training plan for the home. The registered person must ensure that a training plan is developed for the staff team in the home and that all staff have an individual training profile, these remain outstanding requirements. There was some evidence of training and this was linked to the needs of service users and all staff were up to date with their mandatory training, including infection control. Although staff have completed the medication training they have not received feedback yet. All staff have now had briefings on the Protection of Vulnerable adults. The supervision records of four staff were examined as part of the inspection process and two members of staff were spoken to. Although supervision had improved it still did not meet the requirement of 6 times per year. One member of staff had received 1 session, another member of staff 3 sessions since November 2005, another 2 sessions since June 2005 and the fourth 3 sessions since November 2005. Comments received from relatives included “highly satisfied” and “the carers @285 are exceptionally caring and very friendly” Several staff commented that additional staff would be beneficial to enable service users to fully enjoy leisure and community activities. DS0000000916.V299624.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 and 42 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The Commission for Social Care Inspection is concerned about the management and standards of care in the home. There have been a high number of requirements outstanding from previous inspection and the management team have been slow to respond. EVIDENCE: DS0000000916.V299624.R01.S.doc Version 5.2 Page 24 The previous manager has resigned from her post leaving a high number of requirements from the previous inspections outstanding. Staff at the home commented to the inspector that it had been a difficult time working with the previous manager and that they had felt unsupported. A new manager has been appointed to the home and had only been in post for four weeks at the time of inspection, she has not yet submitted her application to become the registered manager of the home. She has a variety of skills, relevant qualifications and experience and has managed care homes in the past. The manager informed the inspector that she was well aware of the requirements made at the previous inspection and was working towards ensuring they were all met. As part of the inspection all health and safety and the maintenance certificates were examined, all were available and up to date. A quality assurance system has commenced within the home and several meetings have taken place with relatives to discuss the running of the home however this needs to be further developed to ensure that all stakeholders are given an opportunity to contribute to the ongoing development of the service. The inspector has been informed that all of the Policies and procedures have been updated and that it is Avocet’s intention to hold workshops to introduce the new procedures and ensure all understand them and work within them. Regulation 26 visits are undertaken by the trustees of Avocet Trust, the manager has commenced staff meetings and house meetings and management meetings take place monthly. Consultation with stakeholders, service users and families need to take place to ensure everyone is given the opportunity to contribute to the running of the home. DS0000000916.V299624.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 x 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 1 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 2 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 1 1 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 1 x 1 x 2 3 x 2 x DS0000000916.V299624.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 YA6 YA23 Regulation 15 Requirement The registered person must ensure that all service users have an individual plan that covers all aspects of personal, social and health needs. (Timescale of 13/9/05 and 30/01/06 not met) The registered person must ensure that individual plans are reviewed at least 6 monthly and amended in light of changing needs. (Timescale of 13/9/05 and 31/03/06 not met) The registered person must ensure that risk assessments are in place for areas that pose a risk to service users and which must include up to date moving and handling assessments. (Timescale of 31/1/06 not met) The registered person must ensure that where service users display behaviours that are likely to cause harm to themselves and/or others, that a behaviour management plan is put in place that all staff understand and follow. (Timescale of 31/3/06 DS0000000916.V299624.R01.S.doc Timescale for action 31/08/06 2. YA6 YA23 15 31/08/06 3 YA9 YA23 13 (6) 31/08/06 4 YA7 YA23 13 (6) 31/08/06 Version 5.2 Page 27 not met) 5 YA12 YA13 YA14 6. YA19 YA23 13 (1a and b) 16 The Registered person must ensure that activities are provided that meet the diverse needs of the service users and meet their assessed needs. The registered person must ensure that service users health needs are met and that detailed records are kept in respect of this. Service users must be offered annual checks and health action plans must be prepared for service users in partnership with health professionals. (Timescale of 13/9/05 and 30/01/06 not met) The registered person must ensure that service users that need specialist diets are assessed by a speech and language therapist and/or a dietician and that there advice is followed. (Timescale of 31/3/06 not met) The registered person must ensure that all staff responsible for administering medication have received training and have their competency assessed. (Timescale of 31/12/05 and 31/03/06 not met) The registered person must ensure that medications are stored appropriately and administered to service users as per the instructions. The registered person must ensure that the bath is repaired or replaced. The registered person must ensure that at least 50 of staff are qualified to NVQ level 2. (Timescale of 31/03/06 not met) The registered person must DS0000000916.V299624.R01.S.doc 31/08/06 31/08/06 7 YA17 YA19 13 (1a and b) 31/08/06 8 YA20 YA23 18 (ci) 31/08/06 9 YA20 YA23 18 (ci) 31/08/06 10 11 YA29 YA32 12,13 18 30/09/06 31/03/07 12 YA35 18 31/08/06 Page 28 Version 5.2 13 YA36 YA23 18 14. YA39 24 ensure that a training plan is developed for the staff team in the home. (Timescale of 31/03/06 not met) The registered person must ensure that all staff receive formal supervision at least 6 times per year. (Timescale of 31/03/06 not met) The registered person must further develop the quality assurance system within the home that ensures the views of service users and their families are taken into consideration and the service is continually improved. 31/12/06 30/11/06 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 YA39 Good Practice Recommendations The registered person must ensure that the manager of the home is registered with the CSCI and that the home is well run and managed at all times. DS0000000916.V299624.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: 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 DS0000000916.V299624.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. 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!