Inspection on 24/01/06 for 281 - 287 St Georges Road

This inspection was carried out on 24th January 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 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 19 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 12/06/06

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 Unannounced Inspection 24th January 2006 09:30 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 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 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 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. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 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 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To retain one service user over 65 years of age. Date of last inspection 13th September 2005 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. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 hours on the 24th January 2006 and 1 hour on the 30th January 2006 and was unannounced. A tour of the premises took place, staff files, care records; staff lists and training records were all examined. The Quality Assurance manager assisted the inspector, as the homes manager was away on training on the day of the inspection. 4 of the staff and a senior support worker were spoken to. Care practices and interactions were observed during the inspection. Service users that were at home on the day of inspection were seen and spoken to. The manager was spoken to at the second visit on the 30th January2006. An additional monitoring visit was undertaken specifically to 287 St Georges Rd on the 6th December 2005 following concerns raised by the local authority as to the standards of care at the home. That visit will be referred to within this report. The inspector was concerned that improvements required at that visit had not been progressed in a timely manner and therefore 4 immediate requirement notices were left at this inspection. What the service does well: What has improved since the last inspection? Personal records are now being stored safely and in accordance with the Data Protection Act. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 6 The registered person has undertaken a review of staffing (grades) and adjusted the staff complement in 287 St Georges Rd to ensure that there is the correct skill mix/competence in the house to support new staff and ensure service user needs are met. New staff are now registered for their LDAF induction and will be commencing soon and other service specific training had been booked and will be provided soon. The new manager has submitted her application to be registered with the CSCI to ensure that they are a suitable person to manage the home. What they could do better: At the time of the inspection the home had a manager however she needs to be registered with the CSCI, in order to give service users and staff a sense of stability. Each person living at the home should have a detailed individual plan, which guides staff on how their needs could 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. Staff working at the home have not had all the training that they must have by law to do their job. They have not had all get the special training they need to help them to look after the people living at the home. This means that service users needs may not be met. Avocet trust needs to provide more training for their staff, especially in the areas of medication, mandatory training, Protection of Vulnerable Adults, NVQ level 2 and LDAF induction so that all of the service users needs can be met. 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. The registered person must ensure that Avocet,s policies and procedures (rules) are reviewed and amended in line with changes in legislation and best practice guidance. To make sure that the home is safe for the people that live there, all equipment and services must be maintained and serviced regularly. To make sure that the home is safe and comfortable for people living there redecoration and repair in specific areas must take place. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 7 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. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 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 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 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. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 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): 6,9,10 Service users do not have a service user plan that reflects their full range of needs thereby placing them at risk. Without this there is no assurance that their care needs will be met. Service users that display behaviours that pose a risk either to themselves or others do not have behaviour management guidelines to evidence that they or their representatives have agreed to any limitations on facilities, choice or human rights. EVIDENCE: NMS 7 and 8 were met at the previous inspection; therefore they were not assessed at this inspection. At the additional visit on 6th December NMS 10 was not met as the inspector was informed that some supervision records could not be located and personal records were not being stored safely. At this inspection the inspector observed that all staff supervision records were now being stored in locked cabinets with the senior support workers and the manager holding the keys. Information was 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 11 observed to be securely kept and handled in accordance with the Data Protection Act. Three service users care files were examined as part of the inspection process, one of the care files in 285 was detailed and up to date however the staff were still following a physiotherapy programme for “rough and tumble” that was developed in 2001. There was no evidence of this being updated, amended or reviewed to ensure it was still appropriate for the needs of the service user, a requirement has been made in respect of this. 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 inspector was informed that whilst one particular service user was waiting for wheelchair services to attend to his wheelchair there was a high risk of him tipping his wheelchair over and staff needed to be vigilant and ensure his wheelchair was always placed against a wall when he is in it to minimise the risk of him tipping it over. A written risk assessment was not in place for this and a requirement has been made in respect of this. The care file and individual plan in 287 St Georges Rd that had been examined during the monitoring visit in December 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. Although there were protocols in place for the management of the service users care/ temperature fluctuations at the inspection on the 24th January there were still several different instructions, which could be confusing and misleading for inexperienced staff and none of the care instructions were written up as part of the individual care plan. There had been some improvement in the night time monitoring and recordings however this was not consistent with the protocol which mentioned the temperature not going lower that 65 degrees Fahrenheit however staff recordings were in Celsius. Staff spoken to said they had not received any training for how to monitor temperature or how to keep the records. An immediate requirement notice was left requiring that this be attended to immediately, however at the follow up visit on the 30th January a new protocol had been prepared that was much clearer and detailed. This particular service user had not had a care plan review although the inspector was informed that it was scheduled for the 30th January and that all the other service users in 287 St Georges rd had. The third care file examined in 281 St Georges Rd was again lacking in detail and had not been amended or reviewed since there was no evidence of care reviews having taken place. This service user was under the care of a dietician 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 12 and had been on a PKU diet, however the monthly weight records showed the last recorded weight as being in June 2005. This particular service user can occasions display behaviours that can be difficult to manage and specific techniques or methods of communication are required in order to minimise the risks. The care plan stated “see behaviour management strategy” and “see clinical psychologists guidelines” neither if which could be located in the file. For this particular service user there was a moving and handling assessment that stated when the service user was unable or unwilling to stand and walk when getting out of the bath to use the “commode” to transport her to her bedroom from the bathroom. This is both unsafe and undignified practice and the moving and handling assessment must be reviewed and amended. 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. All service users had a key worker. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 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): 12,13,15,16,17 Service users are assisted to continue their personal development and have access to the community for a wide range of leisure pursuits. Family contact is maintained, however EVIDENCE: The inspector was informed that none of the service users are engaged in work placements however all of the service users engage in a wide range of activities to continue their opportunities for personal development. The inspector was informed that this had been a priority of the managers to ensure that service users had access to the community and a varied programme of activities. Some service users attend Avocets five senses day service and take part in activities. Service users enjoy an active social life which is detailed in their individual care files, such as bowling, swimming, shopping, visits to the hairdresser, walks and 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 14 out for meals at the pub, visiting friends, one of the service users support Hull City AFC. 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 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 have been assessed by the dietician and the home follow the recommendations given, however the inspector was informed that all of the service users in 287 St Georges Rd are on a liquidised diet and there was little evidence as to how this decision had been reached. 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. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 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 The service users physical and emotional needs are met by well meaning staff, however the poor access to health professionals, poor record keeping and inadequate training provided to staff compromises this. 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 untidy and some guidance and records could not be located. The service manager explained to the inspector that one service user had been having some health problems and that the staff had been supporting her to access health provision, there were some decisions to be taken regarding her ongoing health care however there were no records in the care file to support and evidence this and the IPP/care plan had not been updated to reflect her changing needs and support required. The registered person must ensure that adequate records are kept to evidence that service users health is monitored and potential complications and 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 16 problems are identified and dealt with at an early stage, including prompt referral to an appropriate specialist. Three service users care files were examined as part of the inspection process, one of the care files in 285 was detailed and up to date however the staff were still following a physiotherapy programme for “rough and tumble” that was developed in 2001. There was no evidence of this being updated, amended or reviewed to ensure it was still appropriate for the needs of the service user, a requirement has been made in respect of this. The home has policies and procedures for the administration of medication however not all staff have 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. 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. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 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): 23 The staff team are not fully aware of the Protection of Vulnerable Adults policies and procedures and their responsibility within these therefore strategies are not in place to ensure that service users are protected from abuse, neglect and harm EVIDENCE: NMS 22 was met at the previous inspection; neither the home nor the CSCI had received any formal complaints about the home since the previous inspection, therefore this standard was not assessed at this inspection. There had been a POVA referral to the local authority, which resulted in an additional visit being undertaken by the CSCI in December 2005. Requirements made at this visit have not been progressed in a timely manner. From discussion with staff it was apparent that they were not fully informed about the Protection Of Vulnerable Adults Policies and Procedures and their responsibilities within this. There was still no evidence that all staff had received any training or briefings. The inspector was informed that the manager intends to cascade some in house training with a questionnaire to determine staffs understanding, this must be undertaken as soon as possible. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Service users live in a home whose appearance was generally run down with holes in plasterwork and worn, dirty carpets. EVIDENCE: All of the NMS were assessed at the previous inspection and met, however at this inspection the inspector noted that some of the houses appeared run down with paint and plaster worn away on the walls, carpets stained and worn and kitchens doors and drawer fronts loose and in need of renewing. 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. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 19 Two houses have a relaxation room and the house without has an additional lounge. Three houses have a communal lounge/dining area, kitchen, laundry and bathroom. One house has an additional bathroom. 287 St Georges rd. 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 registered person must ensure that the lounge and hallway are redecorated and new carpets fitted. 285 St Georges Rd The bedrooms have been decorated and new carpets fitted in three bedrooms and the hallway. The registered person must ensure that the bathroom and lounge are decorated and new flooring fitted. They must also ensure that the changing table is repaired or replaced. 281/283 St Georges rd. The registered person must ensure that both of these houses are redecorated and new carpets fitted. 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. The kitchens in all of the houses are looking tired and dated and would benefit from replacement or refurbishment. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35,36 Service users are cared for by a staff team that are well meaning and caring however little supervision is taking place and there is a lack of training both mandatory and service specific and all of this leads to service users needs not being adequately met. EVIDENCE: NMS 31,33 and 34 were assessed and met at the previous inspection therefore were not assessed at this inspection. 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. Since the additional monitoring visit to 287 St Georges Rd the staffing in that house has been reviewed and altered. A temporary full time senior support worker been drafted in, a full time grade “c” staff appointed and one of the staff has been upgrade to a “b” grade meaning that there is a better balance of grades, skills and competencies within the house to meet service users needs. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 21 New staff appointed have received their workbooks and are registered for their LDAF induction. The inspector was informed that this is commencing very shortly however remains as an outstanding requirement until all new staff have completed it. 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 31 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 31 staff only 2 staff have NVQ level 2 and there are 2 registered and working towards it. 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, e.g. the local authority will be providing epilepsy training 1st February 2006 and CTLD will be providing postural management training on 31st January and 2nd February 2006 and staff have been booked on many training courses to bring them up to date however it was apparent that not all staff were up to date with their mandatory training, specifically infection control. Although staff have completed the first two modules of the medication training they have not completed the third module which includes a competency check. Staff spoken to were not clear about their responsibilities with regard to the Protection of Vulnerable adults and had not received any briefings and/or training, although the inspector was informed that the manager intends to cascade the training in house with a questionnaire at the end to demonstrate staffs understanding. The supervision records of two staff were examined as part of the inspection process and one member of staff was spoken to. Although supervision had improved it still did not meet the requirement of 6 times per year. One member of staff had received 3 sessions since February 2005, another member of staff 3 sessions since June 2005 however the other member of staff said they hadn’t had supervision for 5 and half years. (They had been working as a bank staff but still should have received supervision pro rata to the hours they had worked). 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 22 Although improved this is still not providing staff with support and direction that they need. The registered person must ensure that all staff receive formal recorded supervision at least 6 times per year, this remains an outstanding requirement form the previous inspection.. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 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): 37,40,42 The policies and procedures are out of date and do not reflect current practices in the home. Service users live in a safe environment however the lack of some maintenance certificates compromises this. EVIDENCE: NMS 39 was met at the previous inspection; therefore it was not assessed at this inspection. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 24 A new manager has been appointed to the home and has submitted her application to become the registered manager of the home. As part of the inspection on the 24th January 2005 health and safety and the maintenance certificates were examined, not all could be located. There were up to date records for PAT and the maintenance of the hoists however there were no up to date certificates for the fire alarm and emergency lighting the one on the file dated 2004, no gas certificate, emergency lighting or 5 year electric hard wiring certificate. An immediate requirement notice was left to ensure that all of the certificates were located or maintenance/servicing was carried out by 30/1/06.a follow up visit was carried out on the 30th January, at this visit, the fire extinguisher servicing certificate had been located, the boiler had been serviced on that morning and the last fire drill had been on the 27th January 2005. However there was still no evidence of gas safety and electrical hard wiring certificates, therefore requirements have been made in respect of this. Policies and procedures were examined as part of the previous inspection since then some have been updated, one of these being the use of physical interventions. The quality assurance manager is making steady progress in reviewing and amending the policies and procedures in line with changes in legislation and best practice guidance and the timescale for completion has been agreed at 31/3/06. 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 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 x 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 x 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 x x 2 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 1 x x 2 x 2 x 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 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 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 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 not met) The registered person must ensure that risk assessments are put in place for areas that pose a risk to service users and which include up to date moving and handling assessments. 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. The registered person must ensure that service users health needs are met and that detailed records are kept in respect of DS0000000916.V279311.R01.S.doc Timescale for action 30/01/06 2. YA6 15 31/03/06 3 YA9 13 (6) 31/01/06 4 YA9 13 (6) 31/03/06 5. YA19 13 (1a and b) 30/01/06 281 - 287 St Georges Road Version 5.1 Page 27 6 YA17YA19 13 (1a and b) 7. YA20 18 (ci) 8. YA23 13 (6) 9 YA24 23 10. YA32 18 this. Service users must be offered annual checks and health action plans must be prepared for service users. (Timescale of 13/9/05 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 their advice followed. 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 not met) The registered person must ensure that all staff receive training in the protection of vulnerable adults. (Timescale of 31/12/05 not met) The registered person must prepare a plan and undertake refurbishment of the houses in areas specified. The registered person must ensure that at least 50 of staff are qualified to NVQ level 2 The registered person must ensure that all staff are up to date with mandatory training and this must include infection control. (Timescale of 31/12/05 not met) The registered person must ensure that a training plan is developed for the staff team in the home. The registered person must ensure that all staff have an individual training profile (Timescale of 31/12/05 not met) The registered person must ensure that all new staff receive DS0000000916.V279311.R01.S.doc 31/03/06 31/03/06 31/01/06 31/03/06 31/03/06 11. YA35 18 31/03/06 12. YA35 18 31/03/06 13. YA35 18 31/03/06 14. YA35 18 31/03/06 Page 28 281 - 287 St Georges Road Version 5.1 15. YA36 18 induction training that meets LDAF standards. (Timescale of 13/9/05 not met) The registered person must ensure that all staff receive formal supervision at least 6 times per year. The registered person must ensure that the manager of the home is registered with the CSCI The registered person must ensure that Avocets policies and procedures are updated and amended in line with legislation and best practice guidance. The registered person must ensure that all up to date maintenance and servicing is undertaken and certificates retained. 31/03/06 16. YA37 8 31/03/06 17. YA40 24 31/03/06 18. YA42 24 30/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor 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 281 - 287 St Georges Road DS0000000916.V279311.R01.S.doc Version 5.1 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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