CARE HOME ADULTS 18-65
3 Moultrie Road 3 Moultrie Road Rugby Warwickshire CV21 3BD Lead Inspector
Catherine Mundy Key Unannounced Inspection 14th November 2006 09:30 3 Moultrie Road DS0000004314.V315130.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 3 Moultrie Road DS0000004314.V315130.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. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 3 Moultrie Road Address 3 Moultrie Road Rugby Warwickshire CV21 3BD 01788 547585 01788 547585 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) www.rethink.org Rethink Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 27th January 2006 Brief Description of the Service: 3 Moultrie Road is a large, three-storey, Victorian town house, close to the centre of Rugby. It is owned and managed by Rethink (formerly The National Schizophrenia Fellowship). The Home is domestic in nature and is indistinguishable as a care home from the neighbouring properties. The rooms are large and airy and generally well maintained. The home caters for six service users with enduring mental health problems, providing 24-hour support and encouragement to enable service users to regain their independent living skills. The Home is within walking distance of the town centre; there are accessible gardens to the rear of the property. The home currently has two service user vacancies. The current weekly charge is £287, with additional charges made for toiletries, clothing and personal items, hairdressing and activities away from the home. The manager provided this information on 14th November 2006. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced. It took place on 14th November 2006 between 9.30am and 2.30 pm. During this time records relating to the service users and the management of the home were examined and service users, staff and the manager spoken with. The inspection also included a tour of the communal areas of the home and two service users bedrooms. A pre-inspection questionnaire and comment cards were provided to the home. These had not been completed. This inspection focused upon compliance with all of the key standards. Since the last inspection the arrangements for the management of the home have changed. The registered manager has taken a period of leave and a team leader has taken on the management role. She confirmed that she receives support from the staff, other managers within the organisation and the area manager to assist her with her new role. What the service does well:
The philosophy of the home is to support the service users to develop and maintain skills, gain confidence and become independent with a view to progressing from residential care into a supported living or an independent living environment. The service users continue to have a plan of care (recovery plan) that addresses their needs and identifies their aspirations. The level of support that they prefer to receive is clearly documented. These plans are regularly reviewed and updated with the service user and their key worker. Any risks identified are managed appropriately. The staff have a good understanding of the service users needs and aspirations, they adapt the levels of support that they provide to reflect the individuals needs, abilities and the progress that they have made. The service users stated that the staff are approachable and will spend time listening to them and helping them to overcome any difficulties and anxieties. During the inspection the service users were treated with dignity and respect. The service users continue to receive support from the relevant health and social care professionals. All of the documents seen were well ordered and up to date. The manager stated that she intends to review the format of the service users files to make current information more easily accessible to the staff. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 6 The service users continue to be able to participate in a broad range of activities that reflect their personal preferences, promote their independence and that they enjoy. The home provides some activities for the service users. There is a broad range of videos and DVD’s as well as board games and craft materials. Communal activities such as cinema trips and bingo nights are also organised by the staff. The service users are encouraged to access community based activities in the evenings and at weekends and to attend a resources centre. One service user said that she intends to enrol in full time education to enable her to gain a professional qualification. The remit of the home places emphasis upon the service users taking responsibility for household tasks. The service users are responsible for household chores, attending to their laundry and planning, purchasing and preparing their own meals. The service users are given a weekly budget for this. The level of support that is provided by the staff is recorded in the service users recovery plan. The home arranges regular communal meals to enable the service users and staff to share a meal together. The service users said that this could be a takeaway or fish and chip supper. A traditional Sunday lunch is also prepared. The service users are invited to make a financial contribution to these meals using their weekly food budget. The service users are actively encouraged to make decisions for themselves. The home is comfortable, clean and homely and reflects the individual needs and personal preferences of the service users, the atmosphere in the home is welcoming. Observations during the inspection indicated that the service users felt relaxed and comfortable. The staff and service users are working together to redecorate the smoking lounge. The home hold regular service user meetings, which enable the service users to be actively involved in the running of the home. The service users confirmed that if they raise a concern or make a complaint they are confident that this will be addressed by the home. What has improved since the last inspection?
There were no requirements made at the last inspection. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 3 Moultrie Road DS0000004314.V315130.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 3 Moultrie Road DS0000004314.V315130.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): 2, 3 and 4 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with sufficient information and opportunity to enable them to make an informed decision as to whether to accept a placement in the home. They can be confident that the home will support them to meet their needs and aspirations. EVIDENCE: The home provides accommodation for six service users; there are currently two vacancies. Discussions with the manager and staff and other information available confirms that the home follows an acceptable procedure prior to offering a placement to a prospective service user. Referrals to the home are received from the service users social worker. Two members of staff visit the service user; they make an assessment of their needs and whether these can be met and provide the service user with information relating to the home and the service that is provided. Once a decision is made to proceed the prospective service user is invited to visit the home. The service user is able to stay for meals and to stay overnight. The pace of this and number of visits is dependant upon the needs and wishes of the individual service user. Once a decision is made to move in, the service user is invited to stay in the home for a month’s trial. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 10 Discussions with the staff confirmed that once the service user had moved into the home a plan of care, including short and long term goals would be developed with the service user. The level of support provided by the staff is dependant upon the needs and abilities of the service user and the progress that they make. It is clear in discussions with the current service users, staff, examination of service users files and observations made during the inspection that the philosophy of the home is to support the service users to develop and maintain skills, gain confidence and become independent with a view to progressing from residential care into a supported living or an independent living environment. 3 Moultrie Road DS0000004314.V315130.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system in place continues to provides the staff with sufficient information to enable them to support the service users to achieve their goals and meet their identified needs. The service users are actively encouraged to make decisions about their lives. EVIDENCE: A sample of service users files were examined. These contained sufficient information to demonstrate that the service users have an up to date plan of care that details how their assessed needs are to be met. Risk assessments have been completed and risk management strategies developed where these are necessary. There is evidence that the service users are involved in developing their care plans and are consulted when these are reviewed. The aim of the home is to support the service users to move into a more independent living environment. Each of the files examined included a ‘recovery plan’. This identified the service users long and short-term goals. The plan detailed the support that is required to enable the service users to
3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 12 achieve these goals. There is evidence that the level of support provided has been agreed with the service user. The service users and their key worker review this each month during the service users monthly support session. In addition to this the service users also have 1:1 meeting with their key worker each week. Discussions with the service users and staff, examination of the service users files and observations during the inspection confirmed that the service users are actively encouraged to make decisions that affect their everyday lives. The service users confirmed that the staff provide support to assist them to make decisions when this is necessary. 3 Moultrie Road DS0000004314.V315130.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): 11, 12, 13, 15, 16 and 17 The quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users are provided with opportunity and encouragement to develop and maintain independent living skills to enable them to live ordinary and meaningful lives. EVIDENCE: Discussions with the service users and staff, examination of service user files and observations during the inspection confirm that the service users are able to participate in a range of activities that promote their independence and that they enjoy. The home has a large selection of videos and DVD’s as well as board games and craft equipment for the service users to use. Information displayed on the notice board confirms that the home also arrange group activities such as cinema trips and bingo evenings. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 14 Discussions with the service users and examination of activity records confirmed that the service users are able to access community based support groups. One service user stated that she attends a resource centre where she is able to drop in for a coffee and meet friends. She also stated that she has enrolled in a programme of full time education that will begin in the new year, completion of this course will enable her to gain a professional qualification. The service users also confirm that they are able to participate in community based activities in the evenings, these include pursuing hobbies and going swimming. The service users are responsible for maintaining the cleanliness of the home. This is agreed with the service users as part of their recovery plans. A timetable of domestic chores has been developed and is on display in the home. The service users spoken with stated that they are happy with this and appeared to enjoy the responsibility. Records examined, discussions with the service users and staff and observations during the inspection confirmed that the service users are responsible for planning, purchasing and preparing their own meals. Each service user has their own kitchen cupboard and space in the fridge to store their food. The home provides each service user with a food budget at the beginning of each week. Staff support is provided if this is required. Each Sunday the staff and service users prepare a traditional lunch. The service users said that the home also organise to have ‘take-aways’ and ‘fish and chip suppers’. These occasions provide the service users and staff opportunity to share a meal together. The service users and staff are invited to make a financial contribution towards this. The service users are able to use their individual food budget for this. Records are kept of the monies received by the home to provide these meals. One service user showed the inspector the content of her kitchen cupboard. This contained a variety of food and drinks to enable the service user to prepare the meals that had been planned. The service user confirmed in discussion that she had sufficient understanding of ‘healthy eating’ to enable her to make a choice to do so if she wished. On the day of the inspection the service users were observed to move freely around the communal areas of the home and to access the community independently. Each of the service users have a key to their bedrooms, the service users confirmed that they are able to keep their belongings private. They confirmed that the staff ask their permission before entering their bedrooms. The service 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 15 users are able to open their own mail, staff support is provided to assist the service users with this if required. Discussions with the service users and staff confirmed that the service users continue to be able to have visitors in the home, and to maintain links with family and friends. The home has a payphone for the service users to use. The staff said that they would help a service user to use the phone if they were unable to encourage the service user to do this for themselves. The manager stated that family and friends are invited to the home for social events if the service users wish. Service users that have previously lived in the home are also welcome to join in communal meals; if the exiting service users are in agreement that they should be invited. The service users confirmed this. Visitors are also expected to make a financial contribution to the meal. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 The quality in this outcome area is adequate. This judgement has been made using all available evidence including a visit to this service. Although the service users receive personal support and health care in a way that they prefer, which respecting their privacy and promotes independence. Their medication needs may be compromised by a lack of staff training. EVIDENCE: The service users files examined detailed the level of support that they wish to receive to enable them to reach their goals. Discussions with the staff confirmed that they are aware of the content of the service users plans and are flexible in their approach to supporting the service users depending upon their needs, abilities and the progress that they have made. The role of the staff is that of a facilitator rather than ‘doing for’. The service users stated that the staff are approachable and will spend time listening to them and helping them to overcome any difficulties and anxieties. During the inspection the staff were observed to support the service users in a way that promoted their independence and respected their privacy and dignity. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 17 The needs of the service users are such that assistance with personal care is not required. The service users continue to receive support from a variety of health care professionals including a consultant psychiatrist. Routine health screening is also carried out at the local GP surgery, dentist and opticians. Appointments are recorded in the service users files with detailed information as to the outcome for the service user. The home retains responsibility for ordering, storage, administration and disposal of medications for the majority of service users. Medications are stored securely, and records maintained of medication administration. One service user chooses to retain responsibility for their own medication. This is stored securely within the service users bedroom. Appropriate safeguards are in place to ensure that the service user administers their medication safely. This, along with an assessment of risk is detailed in the service users recovery plan. Although it has been noted at the previous inspection that the staff have received training in the safe administration of medication the staff member on duty at the time of this inspection stated that he had not received any structured training with regard to this. He stated that he had been shown how to administer medication by a previous manager. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 18 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 and 23 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the service users are confident that any concerns raised or complaints made will be listened to and acted upon the service users are not sufficiently protected from abuse by the procedures for managing the service users monies or by the staff training. EVIDENCE: Discussions with the service users confirm that they are aware of the homes complaints procedures and are confident that any concerns raised will be addressed by the home. The service users also stated that they are able to raise concerns at the resource centre. The service users confirmed that the home continues to hold regular house meetings where the service users can discuss issues about the home and raise concerns or make suggestions if they wish to. Dates for these meetings and the planned agenda for the next meeting are prominently displayed within the home. Discussions with the staff and manager confirmed that in the event of a complaint being made or concern raised appropriate action would be taken. Examination of the homes complaints log confirms that the home has not received any complaints since the last inspection. The Commission for Social Care Inspection has not received any complaints or concerns with regard to this service. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 19 The home has demonstrated at previous inspections that in the event of abuse being suspected or an allegation made appropriate procedures would be followed. It was stated that the staff should receive training with regard to adult protection. Examination of a sample of staff files during this inspection identified that this training has not been provided. The manager confirmed that in the event of a service user showing distress or there is a change in their normal behaviour records relating to health and wellbeing will be examined to establish probable cause. Discussions with the staff during this inspection confirmed that should this situation arise they would take appropriate action. However discussions manager identified that in the event that an alleged abuse is reported to her proper procedures would not be followed. A referral to the adult protection team would not be made. The home takes responsibility for the safe keeping of the service users money. This is stored securely within the home and records maintained of expenditure. The service users can access their money when they wish. The home does not have a procedure in place to hand over the responsibility for the safe keeping of the money from one staff member to another. In the event that a discrepancy is found it would not be possible to identify when the error occurred. The manager expressed her commitment to addressing this as a priority. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 20 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 and 30 The quality in this outcome area is good. This judgement was made using all available evidence including a visit to the service. The standard of the environment is good, providing the service users with a safe, clean, comfortable and homely place to live. EVIDENCE: This inspection included a tour of the communal areas of the home and two service users bedrooms. This confirmed that the service users continue to live in a comfortable, clean and homely environment. The service users bedrooms are decorated and furnished to reflect their personalities and lifestyles. There is evidence that the empty bedrooms have been redecorated prior to them being made available to prospective service users. They are painted in neutral colours. The manager stated that the service users will be supported to personalise their rooms and redecorate if necessary once the service users move in. Following the decoration there is evidence of damage to one of the bedroom carpets. The manager expressed her commitment to ensuring that this is addressed before a service user moves into this room. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 21 The service users and staff are in the process of redecorating the smoking lounge. As noted earlier in this report the service users maintain responsibility for the cleanliness of the home. Staff support is provided when required. On the day of the inspection the home was clean tidy and free from odour. Cleaning materials are stored in the laundry. Observation confirmed that sufficient products are available. The service users demonstrated an awareness of how these products should be used. The laundry facilities include a washing machine and dryer. The service users and staff confirmed that the service users attend to their own laundry and the staff launder linen and towels. The facilities are appropriate for the needs of the home. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 22 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, 34 and 35 The quality in this outcome area is adequate. This judgement has been made using all available evidence including a visit to this service. The service users benefit from receiving support from an experienced staff team, who have the skills to enable them to meet their needs effectively, this is compromised by deficits in the homes training programme. The service users are protected by the organisations recruitment procedures. EVIDENCE: Copies of the homes staffing rota were provided during the inspection. Examination of these confirms that there are occasions when there is only one member of staff on duty. It is acknowledged that there are service user vacancies within the home. Observations during the inspection and examination of records relating to the service users confirmed that this level of support is appropriate for the needs and number of the current service users, however staffing ratios should be kept under regular review in the event that the service users needs change and as and when new service users move into the home. Examination of the training records relating to the staff members on duty confirmed that the staff have received a broad range of training to assist them to fulfil their roles effectively. This includes risk assessment, personal safety, suicide awareness, mental health awareness, alcohol misuse, motivational
3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 23 interviewing and anti-discriminatory practice. Mandatory training has also been provided but in some cases this has not been reviewed at regular intervals. The records examined indicated that one staff member has not had fire training since May 2005 and another has not received this training at all. As noted earlier in this report the staff have not had training in the safe handling of medication or in adult protection issues. A sample of files relating to staff recruitment were examined. These contained sufficient information to demonstrate that the home has safe practices when employing new staff members. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 24 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 and 42 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home regularly reviews its performance through a good programme of self-review this would be enhanced if this was completed in consultation with the service users and their representatives. The home takes appropriate action to promote and maintain the health and safety of the service users and staff. EVIDENCE: Since the time of the last inspection the arrangements for the management of the home have changed. The registered manager is taking a period of leave. One of the homes team leaders is fulfilling this role in the interim. She confirmed that she feels that she is supported in this role by the staff team, other managers within the organisation and the area manager. The organisation has systems in place to monitor the quality of the service that is provided. An audit of this service was undertaken by the organisation on 9th
3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 25 February 2005. There is evidence that the home has developed an action plan to address the issues identified. Examination of the records demonstrates that the home has also made a self-assessment of the quality of service that they provide. There are no records to indicate that the service users or their representatives were consulted with this. It is recognised that the service users views are sought in house meetings but this does not give the service users opportunity to make comment anonymously as detailed in Standard 39 of the National Minimum Standards for Younger Adults. Each month the manager completes a health and safety checklist and provides a copy to a representative of the organisation. In addition the organisation complete regular visits to the home to monitor quality as required by Regulation 26 of the Care Homes Regulations 2001. Examination of a sample of records relating to the health and safety of the premise, records relating to the service users and a tour of the home confirm That the home takes appropriate action to maintain the health and safety of the service users and staff. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 26 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 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 27 NO 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 YA20 Regulation 13(2) 18(c)(i) 13(4) 13(6) 18(c)(i) Requirement The provider must ensure that all staff responsible for the administration of medication complete appropriate training. The provider must ensure that mandatory training is provided and reviewed at regular intervals. This must also include adult protection training. Timescale for action 31/12/06 2. YA23 31/01/07 3. YA23 13(6) 4. YA39 24(3) This requirement also relates to Standard 35. The provider must ensure that 30/11/06 the procedures in place for the management of the service users monies are reviewed, with strategies put in place to safeguard the service users. The provider must ensure that 28/02/07 the service users and their representatives are given the opportunity to contribute to the monitoring of the quality of the service as detailed in Standard 39. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA33 Good Practice Recommendations It is strongly recommended that the staffing ratios remain under review as service users needs change and as prospective service users move into the home. 3 Moultrie Road DS0000004314.V315130.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 3 Moultrie Road DS0000004314.V315130.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!
