Inspection on 22/01/07 for 3 Welholme Road Care Home

This inspection was carried out on 22nd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Welholme Road Care Home 12/03/09

3 Welholme Road Care Home 25/03/08

3 Welholme Road Care Home 13/02/06

3 Welholme Road Care Home 27/10/05

3 Welholme Road Care Home 21/02/05

3 Welholme Road Care Home 20/08/04

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

CARE HOME ADULTS 18-65 3 Welholme Road Care Home 3 Welholme Road Grimsby North East Lincs DN32 0DY Lead Inspector Stephen Robertshaw Unannounced Inspection 22nd January 2007 09:30 3 Welholme Road Care Home DS0000002819.V328898.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 Welholme Road Care Home DS0000002819.V328898.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 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3 Welholme Road Care Home Address 3 Welholme Road Grimsby North East Lincs DN32 0DY 01472 359574 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited Michelle Elizabeth Holliday Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16), Physical disability (8) of places 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2006 Brief Description of the Service: 3 Welholme Road is a care home that is registered to provide personal care and accommodation for up to 16 service users with a mental disorder (excluding learning disability or dementia), 8 of whom may also have a physical disability. Prime Life Ltd owns the home. The home is on a main bus route to the centre of Grimsby and overlooks People’s Park. It is in keeping with other properties in the area and has large enclosed gardens with a car parking area. Accommodation is based on two floors. All bedrooms are for single occupancy. A passenger lift offers disabled access from the main house to bedrooms situated on a lower level corridor. Further bedrooms are provided on the first floor. Bathrooms and toilets are provided on both ground and first floors. There is a range of communal areas including two lounges, dining room, and a service users’ kitchen. The home is comfortably furnished and is domestic in character. The current fees for the home are between £284-£653 per week. 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit to the home was unannounced and took place on 22nd January 2007. The inspector was in the home for approximately six and a half hours. The evidence for this report was gathered through a pre-inspection questionnaire that had been returned to the inspector by the management of the home, and through five staff questionnaires and contact that the inspector had with service users, their carers, staff and management working at the home and contact with professional carers that were based in the community. What the service does well: What has improved since the last inspection? What they could do better: The home’s employment procedures for new staff could put the service users at risk of abuse so this must be changed to make sure that they are kept safe. Not all of the service users needs are being met at the home. The manager should make sure that if any of the service users needs change then they have 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 6 a new assessment to make sure that they receive the care that they need and it is in the right placement for them. The home needs to be careful to make sure that any infections in the home are not spread to other service users or staff. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the service users are provided with the opportunity to visit the home before they make a decision to live there. EVIDENCE: The home has an up-to-date statement of purpose and service user guide that explains to the service users the services that are available to them at Welholme Road. This included a description of the home and what the fees were for and identified if there were any other costs that would be passed on to individual service users. The inspector observed the care files for three of the service users living at the home. They all included a full assessment of the service users needs that had been completed before the came to live at the home. This makes sure that the service users can have all of their needs met at the home. The assessments were a combination of the homes pre-admission information and care management assessments of needs. Service users spoken to by the inspector stated that they believed that all of their needs were met at the home. One service user said ‘I’m well looked after here, the staff are friendly and nice’. 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 9 This helped the service user to feel more comfortable at Welholme Road and made it feel more ‘like home’ for them. The inspector spoke to most of the service users living at the home and to all of the staff that were on duty on the day of the site visit. The service users generally found that the staff were able to met their needs and that the staff were ‘helpful’ to them. The interviews with the staff and observation of their training records supported the evidence that the home and the staff can met the assessed needs of the service users. All of the service users that were spoken to by the inspector stated that they or their representatives had been given the opportunity to visit Welholme Road before they made a decision to more there on a more permanent basis. This makes sure that the service users will ‘fit’ in to the home and gives them the opportunity to meet the service users that they would be living with and also an opportunity to meet the staff that would be working with them. This means that if they decide to move in to the home the environment and services should be as they expect and there should not be any controversial areas. All of the care files seen by the inspector included terms and conditions of their residency at the home. This included care management contracts and the homes own contract. This means that the service users know exactly what services to expect from the home that will be paid for through their fees. One of the service users health care needs had deteriorated greatly and he now appears to have quite severe dementia related problems. It is important that his needs are re-assessed as soon as possible to ensure that he receives the appropriate care and support that he requires and receives it in an appropriate placement. At the time of the inspection there was no evidence to suggest that a re-assessment of the service users’ care needs had been requested. 3 Welholme Road Care Home DS0000002819.V328898.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the service users are provided with individual choices and their needs are generally met, however there is room for improvement in the storage and recoding of personal information. EVIDENCE: The inspector case tracked three of the service users living at the home. The current care files were all stored in accordance with the Data Protection Act 1998. However the homes archive files were not secure and were open to anyone to read. The archive records were held in a filing cabinet on the top floor of the home. The filing cabinet was unlocked and a key was not available. The area at the top of the stairs has open access to anyone. Therefore anyone going in to this area can access the personal records in the archive files. The individual care plans have improved in the home and include the service users’ needs and how they should be met at the home. All of the care plans 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 11 seen by the inspector had been regulated on a monthly basis to make sure that the service users’ needs were not changing. There was evidence that where individual needs had changed and new care plans had been implemented. Where appropriate the care plans were supported by risk assessments and there was evidence that these are also evaluated on a regular basis to make sure that they were still appropriate to the needs of individual service users. Care staff maintain diary records for the activities and daily routines of the service users. Some of these had not been recorded. This means that any patterns in the service users’ individual behaviours not be identified and therefore appropriate support and maintenance plans may not be put in to place to minimise any deterioration in the service users health and personal care. The service users are provided with choice throughout their daily lives. This includes the time to rise from and retire to bed and what to eat and where to eat it. Direct observations during the course of the inspection confirmed that the service users were consulted to make their preferred choices. This included the service users being consulted as to where they wanted the bus to take them and if they wanted to go out or not. One service user told the inspector ‘we always get asked where we would like to go on the bus, it changes sometimes because of the weather’. The home has regular service user meetings and the records for these meetings supported the fact that the service users are consulted in relation to what they would like in the home and in the community. The staff that were interviewed by the inspector also confirmed that service users’ opinions were always considered when planning activities in the home and in the community. 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,16,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service users are supported to maintain and develop their personal lifestyles through the services provided to them at the home. EVIDENCE: The individual care plans observed by the inspector included plans that would maintain and develop their social, emotional, communication and independent living skills. This included opportunities for service users to fulfil their individual spiritual needs. Staff interviewed by the inspector stated that they support and encourage the service users to continue with their education or training and enabled them to take part in fulfilling activities. However they also said that due to the service users mental health problems it was often ‘difficult to motivate’ individual service users to become involved in any activities. One service user informed 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 13 that they attended a local college for adult education to develop their mathematic and English skills. The service user said that this made them feel better about themselves as they ‘struggled’ with these areas when they were at school. The diary records seen by the inspector and discussions with service users and care staff supported the evidence that the service users are encouraged and supported to participate in activities and events in the community. Some of the service users care plans identified the support that service users required to access services in the general community. The service users spoken to by the inspector said that they were happy with the frequency and diversity of the activities that were made available to them. The service users’ individual care files showed that they are supported and encouraged to maintain contact with their families and friends. One service user also confirmed to the inspector that ‘visitors can come at any time’ and that ‘they are always made welcome’. The home does not employ any kitchen staff, however all of the care staff undertake food hygiene training and prepare the meals for the service users. Service users care files included an assessment of their nutritional needs. The service user spoken to by the inspector stated that they were very happy with the quality of meals provided for them and confirmed that they have a choice of what they would like to eat. Observation at a meal time supported the evidence that the service users are provided with more food if they are still hungry. Fresh fruit and crisps are openly available to the service users throughout the day. The service users also have access to a small kitchenette at the side of the main kitchen. They have facility here to make hot and cold drinks for themselves and snacks such as toast. Several of the service users living at Welholme Road have completed food hygiene courses. The service users stated to the inspector that this facility made them feel ‘more independent’ and that it meant that they didn’t have to wait and rely on the staff to make drinks and snacks for them. A service user said that although she didn’t have to, she took responsibility for keeping this area ‘clean and tidy’. 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that in general the service users personal and healthcare needs are met at the home, however there were some concerns in relation to infection control practices and omissions on service users medication record sheets. EVIDENCE: The care files observed by the inspector supported the evidence that service users se the appropriate healthcare professionals to meet their individual healthcare needs. This included appointments with doctors, dentists, chiropodist, and psychiatrists. Outside professionals contacted by the inspector stated that the care staff always contacted them at appropriate times to support the home with the service users healthcare needs. Service users also confirmed to the inspector that when they see healthcare professional either in the home, or in the community then they always have the opportunity to be seen in private unless they ask for support to attend the appointments. One service user stated to the inspector ‘I am well looked after and if I need to see a doctor the staff make an appointment for me’. 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 15 However the healthcare needs of the service users could be compromised in the home as infection control policies and procedures are not adhered to by the staff. There were blocks of soap and linen towels in the bathrooms and toilets. This practice could help to spread any infections that there may be in the home. To minimise these risks to the service users, liquid soaps and disposable towels should be provided. Staff spoken to by the inspector stated that they had received infection control training but none of them had realised or identified about the problems in the home’s bathrooms and toilets. However when this was pointed out to them they all acknowledged the risks being put to the service users. None of the service users living at the home administer their own medication. All of the staff administering medication to the service users had received appropriate accredited training. The medication was securely stored and there were no controlled drugs in the home at the time of the site visit. There were some omissions in the service users Medication Record Sheets. This could cause problems if a service user was admitted in to hospital and a clear record of the medication that they had taken was not available. The three care files observed by the inspector all included their last wishes in the event of their deaths. This should make sure that their last wishes are followed. 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the service users are generally protected from abuse at the home, however the home’s employment policies could place the service users at risk of abuse. EVIDENCE: There had only been one official complaint recorded at the home since the last inspection. This had been a dispute between two of the service users and was dealt with internally to the home in line with the homes policies and procedures. There had been an on-going protection case at the home since October 2005. In January 2007 the Crown Prosecution Service decided that there was not enough evidence for the case to be taken any further. The member of staff involved had already been dismissed though the company’s employment/ disciplinary policies and procedures. There was evidence that the staff receive adult protection training. This was as a combination of local authority, NVQ and internal training programmes. The home had a copy of the services protection policies and procedures, however these were supported with the local agreement from North Lincolnshire and not from North East Lincolnshire the area that the home is situated in. It is important that the home obtains the appropriate local 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 17 agreements so that appropriate contacts are identified and as the reporting procedures may differ slightly from the other authorities. The service users spoken to by the inspector stated that they knew how to make complaints if they had one. One service user stated to the inspector that ‘the manager is always her and you can speak with her anytime you want’, and said that they were always ‘listened to’. The staff personnel records showed that they had not all received the appropriate security vetting through POVA first of Criminal Record Bureau checks before they were employed to work with the service users and have access to their personal information. This could place the service users at a serious risk of abuse if a suspected or convicted perpetrator was employed to work with them. The service users spoken to the inspector said that they ‘felt safe’ with the staff that were working with them. There were clear records of all of the service users financial transactions that the care staff supported them with and of the service users’ social fund. 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the environment is suitable to the needs of the service users. EVIDENCE: A tour of the premises supported the evidence that much of the home has been redecorated since the last inspection. This was supported through the homes maintenance and refurbishment plan. This included the communal areas and individual service users rooms. Four of the service users invited the inspector to look around their rooms. These as all been decorated to their own tastes and preferences and included their own pictures, ornaments and small items of furniture. One of the service users stated to the inspector ‘my room has been decorated and I chose the colour of it’. One of the service users showed the inspector a blocked sink in her room. She stated that it had been blocked for about ‘three days and nothing had been done’, when asked by the inspector if they had reported this to the staff the 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 19 service user said that they replied ‘I don’t think I have’. There were no records that the blockage had been reported and the staff on duty were unaware of it. The deputy manager stated that the service user was fairly independent and the staff didn’t go in to their room unless they wee invited, unless a problem was reported to them. The staff when made aware of the problem observed the room and immediately reported the sink to the company’s maintenance team. One of the lounges in the home has recently had a large fish tank installed. The service users spoken to by the inspector stated that this helped them to relax by watching the ‘fish swim around’. Care staff spoken to by the inspector that the inclusion of the fish in the room has appeared to initially have a calming effect on the service users, but most of them don’t take any notice of them anymore. In general the tour of the building found it to be in a good condition. The smoking lounge had been redecorated and was much improved, however the sun was very bright throughout the day in this room causing everyone in the room to squint. The windows would have benefited from having blinds that could be adjusted to allow some light in to the room without compromising the service users vision. A window in the kitchen was badly cracked and the sharp glass could cause injury to the service users or the staff if they came in to contact with it. There were blocks of soap and linen towels left in bathrooms and toilets and this compromised infection control in the home. The staff stated that they acknowledged this problem but added that it was difficult as some service users left their own personal toiletries in the bathrooms and they were not aware that they were there. There was a linen towel in the bathroom with the parker bath, and in the blue bathroom there were four blocks of soap, three sponges and two pumice stones that could have been used by anyone. The linen cupboard was also open and did not have a lock on it. This could also cause infection to be transferred in the home if different individuals used any of the items in the cupboard and put them back or left them there. In the recent bad weather conditions there was some storm damage to the home. This included tiles being dislodged on the roof. There was evidence that actions had been taken to repair the identified areas. There is a choice of communal areas that the service users can use. One of the rooms has been designated as a smoking room. A high percentage of the service users living at the home smoke cigarettes. The main concern with the environment was the open access to the top floor of the home. Archive documents were openly available to anyone accessing this 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 20 area, the toilet was very dirty and the room with the water tanks in was also unlocked and open for anyone to access. The ceiling in the kitchenette area of the home was showing signs of damp. The deputy manager and care staff stated that they were already aware of this problem. The maintenance records in the home supported the evidence that the home has up to date safety certificates for the gas appliances and also for the electrical systems in the home. The electrical certificate included ten recommendations and requirements. All of the requirements had been completed including new ring mains and some new sockets being fitted. The Pat test records in the home were out of date and were last completed in 2005. The insurance certificate in the home was out of date, however the deputy manager of the home contacted the central office for the service and they confirmed that the insurance had been updated but for some reason the home had not received a copy of the certificate to display. 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the staff working in the home have the appropriate knowledge and skills to meet the needs of the service users. EVIDENCE: The service users spoken to by the inspector stated that there were always enough staff on duty at the home to help them with their needs. They also said that the staff were all ‘very friendly and helpful’. The staff rotas also supported that there are always appropriate levels of staff available at the home to meet the needs of the service users. Staff training records supported the evidence that the staff have the necessary experience, knowledge and skills to care for the service users. This included records of the mandatory training that is required for the care staff and specialist training in relation to the mental health needs of the service users. Interviews with the care staff also supported the evidence that they have the knowledge and skills to care for the service users. 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 22 The home’s training records suggest that 56.25 of the care staff have achieved NVQ 2 in care or equivalent. This means that they receive training in the work situation to assess their abilities to care for the service users appropriately. Five staff questionnaires were returned to the inspector. These were all very positive and no negative comments were made. All of them referred to the openness and availability of the management. The employment procedures of the home do not ensure the safety and protection of the service users. Staff had been employed to work at the home without an appropriate POVA first or Criminal Reference Bureau certificate to ensure that they had not previously been involved in any abusive practices. The supervision of the care staff to make sure that they are carrying out their roles correctly and to monitor the care plans that they are working to has improved since the last inspection, however the recommended minimum requirements for supervision had not been met by the majority of the staff. 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39 40,41,42 and 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the employment procedures in the home could place the service users at risk of abuse. EVIDENCE: The staff personnel files included clear job descriptions. The staff interviewed by the inspector also confirmed that they had received a copy of their job descriptions and that they were clear of their own roles and those of their colleagues. The manager of the home was not available on the day of the site visit. The deputy manager confirmed that the manager has completed the Registered Managers Award and the NVQ 4 in care and confirmed that the manager 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 24 regularly joins in the mandatory training provided at the home to refresh her knowledge. The deputy manager has completed the NVQ2 in care and is due to commence on the Registered Managers Award. Discussions with service users and interviews with staff supported the evidence that the management in the home is open, positive and approachable. The deputy manager of the home stated to the inspector that she believed that the management was always available to the service users and the staff. The service users spoken to by the inspector stated that they always felt that they were ‘listened to her’. The home has a corporate quality assurance and monitoring system. The central management send out questionnaires to identify the quality of services being delivered through Welholme Road. The system is basic and does not necessarily reflect the quality of the services being provided. Regular service user and staff meetings are held at the home and these are also used by the manager to identify if the services being provided are appropriate to the needs of the service users and allows individuals to air their views and to identify possible areas for development. The home’s policies and procedures were all in position and they had all been evaluated on an annual basis to make sure that they were still appropriate to the home and to enable the care staff to meet the needs of the service users. The current care files and records were all up to date and were securely stored. However the archive records in the home were not stored in accordance with the Data Protection Act 1998. All of the appropriate maintenance and servicing records for the moving and handling equipment and the gas and electrical systems and other safety systems were available for inspection. However the home’s PAT tests were out of date. 3 Welholme Road Care Home DS0000002819.V328898.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 3 2 2 3 3 4 3 5 3 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 1 25 3 26 2 27 2 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 1 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 3 3 3 2 3 2 3 2 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 26 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 YA2 Regulation 14.2a,b Requirement The registered person must ensure that all of the service user have an up to date assessment of their needs, and make sure that no service user is placed outside of the homes registration categories. The registered person must make sure that infection control is maintained throughout the home to ensure the health and safety of the service users and the staff. The registered person must make sure that the medication records in the home are accurately recorded. The registered person must ensure that no staff are employed to work at the home until after they have received appropriate clearance through CRB of POVA first. The registered person must repair or replace the broken window in the kitchen. The registered person must repair the damp ceiling in the kitchenette. The registered person must DS0000002819.V328898.R01.S.doc Timescale for action 22/02/07 2. YA19 YA27 YA30 13.3, 16.2j 23/01/07 3. YA20 13.2 23/01/07 4. YA23 YA34 19.4a 23/01/07 5. 6. 7. YA24 YA24 YA24 23 23 23 22/02/07 22/03/07 22/02/07 Page 27 3 Welholme Road Care Home Version 5.2 8. YA41 17 9 YA43 23.2c make the water tank area on the top floor of the home secure. The registered person must make sure that the archive records in the home are stored in accordance with the Data Protection Act 1998. The registered person must make sure that the home’s PAT test records are up to date and are accurately recorded. 22/02/07 07/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The registered person should make sure that the service users diary records are maintained on a daily basis to make sure that any patterns in their individual behaviours can be identified. The registered person should provide the home with the local multi agency agreement for the Protection of Vulnerable adults. The registered person should consider adding blinds to the windows in the smoking lounge to reduce the sunlight coming in to the room. The registered person should develop a maintenance system that would ensure that individual service users sinks would not remain blocked for several days. The registered person should make sure that the supervision of the care staff working in the home continues to improve and meets the recommended minimum of formal recorded supervision at least six times a year. The registered person should develop the homes quality assurance and monitoring system to reflect the service being provided at the home. The registered person should make sure that the home displays an up to date insurance certificate. 2. 3. 4. 5. YA23 YA24 YA26 YA36 6. 7. YA36 YA43 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 3 Welholme Road Care Home DS0000002819.V328898.R01.S.doc Version 5.2 Page 29 - 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!