Inspection on 25/03/08 for 3 Welholme Road Care Home

This inspection was carried out on 25th March 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Welholme Road Care Home 12/03/09

3 Welholme Road Care Home 22/01/07

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 Ms Wilma Crawford Key Unannounced Inspection 25th March 2008 09:30 3 Welholme Road Care Home DS0000002819.V359809.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.V359809.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.V359809.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 Ltd 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.V359809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd January 2007 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.V359809.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection of the home on 22nd January 2007 including information gathered during a site visit to the home. The site visit to the home was unannounced and took place on 25th March 2008 with two inspectors. Five people living in the home and four staff were spoken with during the visit. The manager was available throughout the visit. The main method of inspection used was called case tracking which involved selecting four people living in the home and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The premises were looked at and the records of eight people living in the home and two staff were examined. An Annual Quality Assurance Assessment (AQAA) document asking for information about the home was sent out before this visit and information from this was included as part of the inspection process of this service. Thirty surveys were sent out to people living in the home, relatives, professionals and staff eleven of these were completed and returned. The comments from these and from discussions during the site visit are also included in the report. The range of fees charged is £367 - £900 per week. These fees are based on a standard fee and an additional package of care based on the individual’s needs. People living in the home, pay for their own newspapers, chiropody treatment and hairdressing. What the service does well: The home has the benefit of an established staff team who have a good understanding of the people living in the home. 61 of the staff team have a national Vocational Qualification at level 2 or above, a further 23 of the staff team are working towards this award. The staff team work together as a team and are well supported by the manager of the home. The people living in the home told the inspector that they felt confident that the manager would sort out any problems that they had. Staff members were observed helping the people who live in the home in a dignified way. The home’s administration, handling and storage of medicines is well managed. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The Annual Quality Assurance Assessment (AQAA) document submitted by the organisation states that the testing of Portable Appliances has not been checked since September 2005, this should be completed on an annual basis. Not all of the service users needs are currently being met at the home. Although the care plans have improved further work needs to be completed in recording more detailed information about identifying changes in individuals behaviour, guidance on how this should be managed and where support has been accessed. Feedback from local professionals indicate that they are not happy with aspects of the care provided in the home, the attitude of staff, the quality of food provided, the lack of provision of activities and the environment of the home. The manager needs to develop links with external agencies and other professionals to ensure that individuals receive consistency in the delivery of their care needs and that this is provided. The home does not provide a menu or maintain a record of food offered to people living in the home. Records of food provide needs to be made available within the home, to demonstrate that a nutritious diet is being offered and a choice of meals are being provided. The staffing levels in the home need to be reviewed to ensure that there are adequate numbers of staff available at all times to meet individual needs. Although the staff team plan for and work flexibly to support people living in the home on the day of the visit additional staffing required to provide1:1 support was not available due to staff sickness. People living in the home said that they had to opportunity to go on day trips, attend local day services and engage in some activities. However on the day of the visit no planned activities were observed in the home. Staff spoken with said that it was difficult to motivate people and felt that they would benefit from further guidance in relation to this. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 3 Welholme Road Care Home DS0000002819.V359809.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 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 People who use this service experience adequate quality outcomes in this area. People are provided with the opportunity to visit the home and are given enough information about the home and its facilities before they make a decision to live there. This judgement has been made using available evidence including a visit to this service. 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 people living in the home. The inspectors examined the care files for eight of the people living in the home. Each included a full assessment of the service users needs that had been completed before the came to live at the home. The assessments were a combination of the homes pre-admission information and community care assessments of needs. The inspector spoke to most of the people living in the home and to all of the staff that were on duty on the day of the site visit. People living in the home found that the staff were able to meet the majority of their needs and that the staff were ‘helpful’ to them. However there were occasions where they had to wait for things, which they felt was a result of the staff team being responsible for all tasks within the home. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 10 One person said ‘This is a lovely home, the staff are marvellous.’ All of the people spoken with stated that they or their representatives had been given the opportunity to visit Welholme Road before they made a decision to move there on a more permanent basis. This offered them the opportunity to meet the other people living in the home and also to meet the staff that would be working with them. The interviews with the staff and observation of their training records supported the evidence that the home and the staff can meet the majority of the individual needs of the people living in the home. 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. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 People who use this service experience adequate quality outcomes in this area. People using the service have their needs generally met, however this is not reflected in the care planning documentation. The judgement has been made using available evidence including a visit to this service. EVIDENCE: Verbal feedback from people living in the home and relatives is that they are involved in the review and development of care plans and that they have the opportunity to discuss any changes or wishes that they have in relation to their care. Individual care plans are in place and covers health, personal and social care needs. Risk management strategies are in place for some areas of need including aspects of daily living. Examination of a sample of 8 care plans showed that there has been considerable improvement in maintaining and reviewing care plans. However, further work needs to be done to ensure that care plans include all the necessary information about specific individual needs. Clear information needs to be in place, detailing how to identify problems arising, what action needs to be taken in respect of this and what information needs to be recorded, for all 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 12 of the people living in the home. An example being, individuals who had identified needs regarding their diet, did not have any guidance for staff to explain how the problem may be presented, what was considered a good diet for the person involved, and what action the staff should take to support the individual. There was no record of food intake in their care plan. Similarly people presenting challenging behaviour, did not have guidance in their care plan to support staff to manage this effectively. On examining records of reviews it was found that agreed actions from these meetings had not always been updated and incorporated into peoples’ care plans. Discussion with staff indicated that they respect the peoples right to make decisions, however recording in daily records was at times judgemental rather than objective. Staff also said that they did on occasions have difficulty in motivating people. These areas need to be addressed in order that the home can progress further and meet all the needs of the people living in the home in their preferred manner. Service users are also regularly consulted via service users meetings, which are recorded. Areas discussed at recent meetings include menus and outings. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 People who use this service experience adequate quality outcomes in this area. People using the service have some opportunities to access some leisure activities and are supported to maintain relationships. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The individual care plans observed by the inspectors included plans that would maintain and develop the social, emotional, communication and independent living skills of people living in the home. This included opportunities for service users to fulfil their individual spiritual needs. Staff spoken with by the inspectors said that they support and encourage people 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’ individuals’ to become involved in any activities. On the day of the site visit no planned activities were observed. One person informed the inspector that they attended a local college for adult education to develop their mathematic and English 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 14 skills. They said that this made them feel better about themselves as they ‘struggled’ with these areas when they were at school. Discussions with other people living in the home supported the evidence that they are encouraged to participate in activities and events in the community, there was only limited evidence of this documented within the care plans seen. Some of the service users care plans identified the support that people required to access services in the general community. People living in the home spoken to by the inspectors said that they would like more activities and the opportunity to develop more independent living skills, for example cooking meals, baking and snack preparation. They went on to say that although there is a designated area for them to use, there is not enough staff available to support them with this activity. Individual care files showed that they are supported and encouraged to maintain contact with their families and friends. One person 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. People spoken to by the inspectors stated that they were happy with the quality of meals provided for them and confirmed that they have a choice of what they would like to eat. Observations during the morning confirmed that people are offered a choice of hot and cold food. People living in the home said that they are able to go out on trips from the home a couple of times each month. Details of trips are displayed in the home. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use this service experience adequate quality outcomes in this area. The majority of people living in the home have their health and personal care needs supported by care plans and risk assessments. The judgement has been made using available evidence including a visit to this service EVIDENCE: The care files observed by the inspector supported the evidence that the majority of people living in the home shave access to 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 there were occasions when people were not supported to attend appointments or had the required information with them, for example information about their compliance with medication. People living in the home 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 person 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.V359809.R01.S.doc Version 5.2 Page 16 However the healthcare needs of the people living in the home could be compromised by the lack of continuation of recording important information and recommendations from consultants or doctors appointment into individuals care plans. Similarly information about any deterioration in individuals’ mental health, also need to be recorded and made available to consultants when people attend appointments. 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 system and records were found to be accurate up to date and well managed. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service experience adequate quality outcomes in this area. The understanding of the arrangements for protecting residents is satisfactory, protecting residents at possible risk of harm or abuse. The judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home spoken with were able to describe how they could use the complaints process and were confident that they could talk to any of the staff if they had any problems. One person stated to the inspector that ‘the manager is always here and you can speak with her anytime you want’, and said that they were always ‘listened to’. However feedback from surveys suggested that some people did no feel listened to by all members of the staff team. The AQAA document stated that no complaints have been received by the home since the last inspection. A safeguarding issue that had been referred by the home had been dealt with appropriately. Concerns raised by the professionals are being worked towards being resolved. Staff spoken with showed that they had a good understanding of their role in dealing with Safeguarding Adults issues. The staff personnel records showed that they had 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 practice ensures that people living in the home are protected from risk. The service users spoken to the inspector said that they ‘felt safe’ with the staff that were working with them. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 18 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. Finances are audited regularly and a report complied. The most recent report found the finances to be managed satisfactorily within the home. Records showed deficits owing to the home from people who were no longer living there. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use this service experience adequate quality outcomes in this area. The residents have been provided with an environment that is generally clean with communal space suitable for their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been a considerable improvement to the environment of the home since the last inspection. The home is cleaner and there were no identified odours on the day of the visit, carpets and soft furnishings had been cleaned. Requirements made at the last inspection in respect of the environment had been completed. 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.’ 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 20 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 entrance hall to the building has ornate coving, this has been discoloured yellow and is need of redecoration. Similarly the skirting boards in the home have been damaged and are in need of repair and redecoration. At the last site visit a requirement was made in relation to the testing of Portable appliances within the home. The AQAA document shows that this work has not been completed, this could put people living in the home at risk. One person spoken with said that they did not have a key to their room and relied on staff to unlock it for them. They also said that they had offered to pay for the cost of the key being replaced. All bedroom doors should be fitted with a suitable lock to ensure resident’s belongings are kept safe, and those residents who are assessed as able should be given a key. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 People who use this service experience adequate quality outcomes in this area. People living in the home are supported by staff who are supervised and undertake training. The staff vetting procedure is sufficiently robust to ensure the safety of the residents. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The current staffing levels consist of the manager, and two care staff during the day and two staff at night. There is no additional ancillary staff available in the home, therefore the care staff have responsibility for the cleaning, cooking and laundry as well as care. In addition to this individual packages of care are provided by the home for individuals where a need has been identified. During the visit, the rota was examined, a staff member had rung in sick and cover had not been obtained for this person. Therefore the staff designated to provide the 1:1 cover was being used in their place. 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. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 22 Interviews with the care staff also supported the evidence that they have a good understanding of individual needs. Staff said that they did on occasions have difficulty in motivating people living in the home and would benefit from training in this area. The home’s training records suggests 6 of the staff team have a National Vocational Qualification at level 2 or above, a further 23 of the staff team are working towards this award. The staff team said that they work well as a team and they are well supported by the manager. All of them referred to the openness and availability of the management. The employment procedures of the home ensure the safety and protection of the service users. Staff who been employed to work at the home had an appropriate POVA first or Criminal Reference Bureau certificate to ensure that they had not previously been involved in any abusive practices prior to starting employment. Staff supervision files showed that staff team receive ongoing supervision with a line manager. Staff also have annual appraisal sessions. People living in the home said that staff do not always have enough time to support them with activities or in the development of their independent living skills. Outcomes for people living in the home could be improved if the staffing levels were reviewed and provided to meet individual needs. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 and 43 People who use this service experience adequate quality outcomes in this area. People using the service benefit from a safe and well managed place to live. Overall the manager has the skills, knowledge and experience to run the home effectively and protect the health, safety and welfare of the residents. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has completed the Registered Managers Award and the NVQ 4 in care and has relevant experience of working with people with mental health needs. 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. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 24 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. Discussions with people living in the home and interviews with staff supported the evidence that the management in the home is open, positive and approachable. Staff and people living in the home stated to the inspectors that they believed that the management was always available to the service users and the staff. The home’s policies and procedures were available in the home and corresponded tom the evidence submitted within the AQAA document. The current care files and records need further development to ensure that all the information required in relation to meeting the individual needs of people living in the home is available. 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 Portable Appliance Testing was out of date. 3 Welholme Road Care Home DS0000002819.V359809.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 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 2 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 X 2 X X 2 1 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA43 Regulation 23.2c Requirement Timescale for action 30/05/08 2. YA6 15(1) 2 a, b, c, d 3. YA33 18(1) a The registered person must make sure that the home’s PAT test records are up to date and are accurately recorded. Ongoing from 07/03/08 Original timescales not met. 30/05/08 The registered person must ensure that information agreed at care reviews is incorporated into the individuals care plan. This should include guidance for the care staff team detailing how the changing needs of the individual can be met. The care plan should be implemented to ensure that individual needs of people living in the home are being met. Ongoing from 30/11/07 Original timescales not met. The registered person must 30/05/08 ensure that there are sufficient staff on duty at all times to meet the needs of the residents accommodated in the home. Ongoing from 30/11/07 Original timescales not met. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 27 4. YA6 14(2) a b 5. YA6 12(1)a 14(2)a b 6. YA24 23(2) b The registered person must 30/05/08 ensure that care plans for all people living in the home contain explicit details of how their individual needs should be met. This should include guidance to the care staff team as to how any issues relating to the individual can be identified and managed and what records need to be maintained in relation to this. The registered person must 30/05/08 ensure that the care plan sets out how specialist requirements will be met, for example managing challenging behaviour or non cooperation of attending hospital appointments. The registered person must 30/05/08 ensure that the coving, cornice and ceiling of the entrance hall, which are stained yellow are redecorated. The skirting boards are also in need of repair and redecoration. 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 YA14 Good Practice Recommendations The registered person should develop a plan of activities for people using the service. This should be developed in agreement with the people living in the home and meet their individual needs. The registered person should consider keeping a menu on display within the home. The registered person should ensure that the home provides a staff team, in sufficient numbers to support service users assessed needs at all times, and that satisfactory arrangements are in place to provide the DS0000002819.V359809.R01.S.doc Version 5.2 Page 28 2. 3. YA17 YA33 3 Welholme Road Care Home 4. YA35 necessary cover in times of absence of staff for example sickness or training. The registered person should provide staff with training in communicating with people with a Mental Health need and developing skills to motivate people. 3 Welholme Road Care Home DS0000002819.V359809.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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.V359809.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!