Inspection on 27/10/05 for 3 Welholme Road Care Home

This inspection was carried out on 27th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 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 22/01/07

3 Welholme Road Care Home 13/02/06

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 27th October 2005 09:30 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 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.V261853.R01.S.doc Version 5.0 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.V261853.R01.S.doc Version 5.0 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) 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.V261853.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2005 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 well decorated, and is domestic in character. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Welholme Road was unannounced and took place on 27th October 2005. The inspection was over an 8 hour period. The management, care staff, and service users were all very open with the inspector and were happy to share information with the inspector. There is currently a protection of vulnerable adults investigation being carried out in relation to the home. The investigation has not yet been completed and will be reported if necessary in the next inspection report. What the service does well: What has improved since the last inspection? 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 6 The quality of the individual care plans have much improved since the last inspection adding clearer and greater detail to the information in relation as to how individual service users needs must be met at the home. Risk assessments are completed for individual service users but they were not all reviewed on a regular basis. A new ramp has been fitted in a corridor of the home to aid access to service users with mobility problems. The handrails need to be replaced in line with the ramp. The management of the home will review the provision of the handrails in the corridor. What they could do better: The homes complaints procedure needs to be updated to make reference to the local office of the Commission for Social Care Inspection. The homes policies and procedures for the Protection of Vulnerable Adults must be updated to include that if there is a suspicion of abuse it is immediately reported to the correct authorities and the home do not conduct any internal investigation without the prior agreement of the adult protection decision maker. Care staff must receive appropriate Protection Of Vulnerable Adults training and the management should ensure that the staff have a working understanding of how to report suspected abuse. The registered person does not sufficiently ensure the welfare of the service users as they employ new staff to work in the home before they have received either a POVA first or Criminal Record Bureau clearance. This could allow possible abusive staff to work at the home. Staff working at the home should be provided with recommended minimum of six formal recorded supervision periods per year. The decoration of the home is in very poor condition in places. The company undertook an audit of the home the day before the inspection however the results of the audit were not available and the requirements in relation to the environment were outstanding from the last inspection. The home does not have a current electrical systems safety certificate. This could mean that the service users are being put at risk and their health and safety is not being supported. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 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. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 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.V261853.R01.S.doc Version 5.0 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): 1,2,3,4 and 5 The service users are provided with the opportunity to choose whether or not to live at the home providing that their individual needs can be met there. EVIDENCE: The homes statement of purpose was updated in February of this year. It includes most of the information required by the regulations but does not include the detail of individual room sizes. The registered provider gives the prospective service users a copy of the floor plan for the home that indicates the sizes of individual rooms. However this may be difficult for some service users to understand. A copy of the homes last inspection was openly available in the homes entrance. There are currently 13 service users in the home and the inspector observed the case file information in relation to three of the service users. All of the files observed by the inspector included comprehensive assessments of the service users needs. This included care management and community mental health team assessments, and pre-admission assessments completed by the home. This makes sure that the home does not admit any service user whose needs it cannot meet The files also included terms and conditions of the individual service users residencies. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 10 Records in the home and discussions with service users confirmed that they were given the opportunity to visit the home before they made a decision to move there on a more permanent basis. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 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): 6,7,8,9,and 10 The individual needs of the service users are care planned to make sure that their lives are comfortable and they have choice in their every day lives. EVIDENCE: The inspector observed the care plans for three service users. The quality of the care plans in the home had improved since the last inspection, including the detail of how individual needs should be met. The homes care plans were directly related to the service users needs that were identified in their original assessments, and corresponded with the needs identified in the service users care management care plans. The care plans are being evaluated and reviewed on a more regular basis however they still do not meet the recommendation of being evaluated on a minimum of a monthly basis to ensure that the service users needs remain unchanged, or additional care plans require implementing. Direct observation and records seen in the home confirmed that the service users are encouraged and supported to make decisions for themselves in the 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 12 course of their daily lives. This included times to get up and retire to bed, what to eat and where to eat. Advocacy information was available in different areas of the home and gave service users details of how to access these services if they wished to. Risk assessments identified if there were any restrictions for service users in their daily lives. Examples of this were accessing the community alone, or using public transport. Otherwise the service users did not face any restrictions in their daily lives and activities. The risk assessments had not been evaluated in conjunction with the individual service users care plans and some of them were several years old and showed no evidence of having been reviewed or updated. Records of service user meetings confirmed that the service users are consulted in how the home and the services that it provides are developed. The meetings showed how the service users were consulted in relation to the meals at the home and activities. Service users also stated to the inspector that the staff ask them for their opinions in relation to different aspects of the services that are provided by the home. The confidential information stored in the home was held in accordance with the Data protection Act 1998. Staff interviewed by the inspector were aware of the homes policies and procedures for confidentiality. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 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 service users at the home have opportunities to develop their personal lifestyles and independent skills identified through their individual care plans. EVIDENCE: The service users individual diary notes and care plans confirmed that they are supported to maintain and develop their social, emotional, communication and independent living skills. There was evidence that the service users access different activities in the community to develop their skills and to encourage their interactions with other people outside of the home. This included attending social services day centres, and accessing the local college for courses including mathematics and English. The records for one service user showed that he enjoyed gardening and did some voluntary work gardening for other people in the community. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 14 The service users stated to the inspector that if they want to access the local community and don’t have the confidence to do this by themselves then they receive support from the staff at the home. The home also at times invites professional performers in to the home to entertain the service users. Service users were recently given the opportunity of a holiday with the home and some of the service users went on holiday with the support of some of the staff. The service users files and discussions with the inspector confirmed that the care staff support them to maintain contact with their families and friends. Individual care plans and diary notes showed how service users daily routines are flexible to promote their independence and choice. There were no restrictions for movement of individual service users unless this was risk assessed and included in their care plans. Service user care plans also evidenced if they were provided with lower levels of support to develop their independence skills. The meals provided for the service users are varied and records of service user meetings showed how the service users are consulted in relation to what they would like including on the menu. The inspector observed a mealtime at the home and witnessed that the atmosphere was relaxed and the service users were unrushed. No service users required physical support to eat, however staff were observed offering appropriate verbal support to service users to ensure that they ate their meals. The service users stated that they were happy with the meals that were provided to them by the home. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18/19/20 and 21 The personal and healthcare needs of the service users are met at the home. EVIDENCE: The home does not provide nursing care. The healthcare needs of service users are met through professional services that are based in the community. This includes GP’s, psychiatrists, community psychiatric and district nurses. Individual care plans identified the professional supporting the health care of the service users and any contact that they had with them. The care plans also identified where service users required support or encouragement to maintain their personal hygiene. Service users and staff both confirmed to the inspector that `the care staff at the home meet these needs. Service users also confirmed that they are always given their own clothes back from the laundry and they choose what they want to wear on a daily basis. Individual care plans observed by the inspector all included an assessment of the service users nutritional requirements. The service users stated that they always enjoyed the meals that were provided for them. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 16 Individual case files identified the homes keyworkers for individual service users. The service users spoken to by the inspector were aware of who their keyworker was and what their responsibilities were to them as a keyworker. One service user was identified as not having a regular keyworker as he builds up a dependency on anyone who provides regular care to him, therefore his care is provided through the whole staff team. The inspector identified that one service user was self administering his own medication. The medication was safely stored in a locked drawer in his bedroom. A letter from the service users community psychiatric nurse confirmed that they were in agreement to the homes self administration of medication policy. The remainder of the service users have their medication administered to them by the care staff. Care staff administering prescribed medication receive accredited medication training provided through a local college on a distance-learning basis. All of the service users care files observed by the inspector included details of their last wishes in the event of their deaths, or alternatively identified if the service users did not wish to discuss these details, and pushing for the information could have a detrimental effect upon their mental health. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 and 24 Service users felt that their views were listened to however the home does not follow the appropriate guidelines to ensure the protection of the service users from abuse, or abusive situations. EVIDENCE: The home has a clear procedure for the service users to follow to make a complaint in relation to the services that they receive at the home. Service users spoken to by the inspector stated that they knew how to make a complaint if they wished to. There were two complaints registered in the home since the last inspection and these were appropriately dealt with by the management of the home. The home has a policy stating that service users and their families will not be victimised for making a complaint. . The home does not complete the necessary safety vetting of staff before they commence working at the home. Staff records showed that they are employed before they receive either POVA first or Enhanced Criminal Record Bureau clearances. The homes policies and procedures for the protection of vulnerable adults included that the management of the home should instigate the investigation of suspected abuse. In all instances the investigation must by carried out by either the local authority POVA representative or the Police and they will decide whether to include other responsible individuals as part of the joint investigation. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 18 At a meeting following the draft report a new POVA policy for the home was shown to the inspector by the registered person. This was more appropriate to the needs of the service users. However all staff working at the home were not aware of the new policies and procedures at the time of the inspection. Following the adult protection incident at the home the manager has introduced a questionnaire to the staff group to identify their knowledge of suspected abuse and how it should be reported. Staff interviewed by the inspector had an understanding of what constituted suspected abuse, but were not all clear on the appropriate reporting systems. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,28,29 and 30 The environment of the home is in very poor condition in the communal areas and this affects the service users in their attitude towards the home and their mood. Other service users stated to the inspector that they were happy with their environment. EVIDENCE: A tour of the premises by the inspector found the home to be badly in need of redecoration both internally and externally. At the time of the inspection a new ramp had been included on a corridor to ease the access for service users. However the handrails had not been replaced on the wall and some service users stated that this caused difficulties for service users in wheelchairs going up and down the ramp by themselves. The decoration in the majority of the communal areas in the home is very drab with wallpaper needing replacing and paintwork badly marked and chipped. The gutters on the outside of the building were overflowing due to the amount of leaves and broken off branches that were in them. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 20 Several service users invited the inspector to look at their individual rooms. These had all been personalised to their individual tastes and preferences. Including furniture items, pictures and ornaments. There is a choice of shared spaces in the home that the service users can choice to use to sit and spend time with their peers, family and friends. The company has recently completed an audit on the homes environment but the results of the audit were not available at the inspection. The home was relatively clean and tidy and free of offensive smells however the appearance of the internal decoration makes the home look dirtier than it actually is. The washing machines in the laundry are programmable to disinfection and sluicing standards. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33,34 and 35 The employment procedures for new staff at the home do not ensure the safety of the service users and therefore service users could be paced at risk of abuse. EVIDENCE: The inspector observed the personnel and training files for 4 members of the homes care staff. The files all included clear job descriptions and work specifications. Interviews with staff showed that they have a clear understanding of their own responsibilities and the responsibilities and accountabilities of their colleagues. New staff are provided with a copy of the General Social Care Councils code of conduct as part of their introductions package. The staff are working towards the homes commitment of 50 of the care staff to have achieved NVQ2 or equivalent by 31st December 2005. Currently 3 staff have achieved the full NVQ 2 award and a further 4 staff are registered on the award and are working towards completing it. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 22 Service users spoken to by the inspector stated that there was always enough staff on duty at the home to meet their needs and that the staff were very responsive to them. Employment records evidenced that not all of the staff are appropriately vetted for safety before being employed to work with the service users. Before staff commence working at the home they must have received as a minimum a POVA first check or a new completed CRB clearance specific to the home. The staff records showed that they had all received terms and conditions for their employment at the home. Training records and interviews with staff supported that they receive induction and foundation training that meets the requirements of the Sector Skills Council. Staff supervision records in the home showed that the levels of supervision are all staff are not meeting the recommended minimum requirement of six formal recorded supervision periods per year (pro-rata). 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41and 42 The management of the home is open and accessible to both the service users and the staff groups. The management do not follow good practice guidelines when employing new staff that would safeguard the service users from abuse. EVIDENCE: The homes manager has completed an NVQ 2 in care, and is close to submitting her completed portfolio for the Registered Managers Award. When she has completed this she is enrolling on the NVQ 4 award in care. The service users and staff interviewed by the inspector stated that the management of the home was open and approachable. The homes quality assurance and monitoring system is still under development. The manager discussed the system with the inspector and how it could be improved including analysis and publishing the results of returned questionnaires. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 Page 24 The homes policies and procedures were very limited and had been approved by a focus group attended by a representatives of the CSCI and Prime Life. The staff were only aware of a pocket size document that gave statements in relation to policies and procedures but does not actually include them. These documents are issued to them when they begin to work at the home but are not updated with individual staff when later editions are printed. The external management of the home completed regulation 26 visits to the home. The records of these visits were observed and were much improved in their content and presentation. The proprietors do not send a copy of their report to the Commission. The majority of the homes health and safety requirements were met however the home still does not have a safety certificate for the electrical systems in the home. This is an outstanding requirement. The registered person must contact their insurance company and obtain confirmation that their insurance will not be nullified if they do not hold the appropriate electrical safety certificate. Unless indicated through a comprehensive risk assessment the radiators in the home must all be provided with low temperature surfaces, or be guarded to protect the service users from possible burns. The safety of the service users is compromised by failure of the management to adhere to safe recruiting practices and leaves them open to abusive situations. 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 3 3 Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X 3 X 2 2 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 2 1 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 3 Welholme Road Care Home Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 1 2 1 X DS0000002819.V261853.R01.S.doc Version 5.0 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA22 Regulation 22 Requirement The registered person must ensure that any person making a complaint in relation to the home or the services that it offers are not harassed. The registered person must ensure that all staff are aware of the homes updated policies and procedures in relation to the protection of vulnerable adults. The registered person must ensure that a maintenance plan for the redecoration for the internal and outer areas of the home is completed and that the identified needs are actioned. The registered person must ensure that all prospective staff to the home receive appropriate vetting to ensure the health and safety of the service users. No staff must be employed by the home unless they have received the minimum of a POVA first clearance. The registered person must ensure that the home has an up to date certificate confirming the safety of the electrical systems, or a letter of confirmation from DS0000002819.V261853.R01.S.doc Timescale for action 27/10/05 2 YA23 12 30/11/05 3 YA24YA28Y 16 30/11/05 4 YA33YA34 18 27/10/05 5 YA42 23 27/11/05 3 Welholme Road Care Home Version 5.0 Page 27 their insurance company that this is not required. 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 2 3 4 5 6 7 Refer to Standard YA1 YA6 YA19 YA29 YA32 YA36 YA39 Good Practice Recommendations The registered person must ensure that the homes statement of purpose includes all of the required information including the sizes of individual rooms. The registered person must ensure that all of the individual care plans in the home are evaluated on a minimum of a monthly basis. The registered person must ensure that individual service users risk assessments are evaluated on a regular basis in conjunction with their care plans. The registered person must ensure that the new ramp fitted in the corridor for easier access to wheelchair users has appropriate handrails fitted to the walls. The registered person must ensure that a minimum of 50 of the homes care staff have achieved NVQ 2 or equivalent by 31st December 2005. The registered person must ensure that all staff working at the home receive the minimum of six formal supervision periods per year (pro-rata). The registered person must ensure that the home has an effective quality assurance and monitoring system. This should include questionnaires, appraisal, planning and publishing of the results. The registered person must make full policies and procedures available to the staff. The policies and procedures must include all of those detailed in appendix 2 The registered person must submit a copy of their regulation 26 visits to the local office of the Commission for Social Care Inspection as required by the regulations. The registered person must ensure that all of the radiators in the home are provided with low temperature surfaces to maintain the health and safety of the service users. Otherwise a comprehensive risk assessment must identify why this is not required at the home. 8 9 10 YA40 YA41 YA42 3 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 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: 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 Welholme Road Care Home DS0000002819.V261853.R01.S.doc Version 5.0 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. 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