CARE HOME ADULTS 18-65
30 Newland Street 30 Newland Street Crumpsall Manchester M8 5RY Lead Inspector
Steve O`Connor Key Unannounced Inspection 12 September 2006 12:30
th 30 Newland Street DS0000021707.V309376.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 30 Newland Street DS0000021707.V309376.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. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 30 Newland Street Address 30 Newland Street Crumpsall Manchester M8 5RY 0161 740 9397 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) Southfields Care Homes Limited T/A The Regard Partnership Limited Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: The home is a terraced house situated in the Crumpsall area of Manchester with easy access to local facilities e.g. shops, services, places of worship, pubs and local transport. The home provides accommodation for up to 3 persons with mental health problems. The service users accommodated are funded to receive staffing on a one to one basis due to the complexity of their needs and their challenging behaviour. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the home was last inspected in March 2006. This information includes an Action Plan sent in response to that inspection report, a Pre-Inspection Questionnaire completed by the home and returned to the CSCI in July 2006, incidents notified to the CSCI by the home and information provided through other people and agencies, including concerns and complaints. During the unannounced inspection site visit time was spent talking with people who live at the home, observing how staff work with people and taking to staff on duty. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. The inspection report of March 2006 highlighted a number of areas that the home needed to work on and improve. The home had addressed some of the changes needed from the last inspection report. However, a number still remained and had to be repeated again in this report. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do with the home. What the service does well:
The home supports people who have long-term mental health problems and would find it difficult to live on their own in the community without support. Through discussions with people, the staff on duty and through observations of their interaction the home showed that it continues to encourage and support people to try to make informed decisions and choices about both day-to-day and long-term decisions. The relationship between people and staff appeared very genuine and positive with a good rapport and interaction between them. People were able to say what they liked and did not like about the house and had good relationships with the staff team. They had the confidence to be able to express their thoughts and worries and that staff would listen to what they had to say. An area that the home continued to take seriously was in maintaining people’s general and mental health. The home supported people to access local general health services such as the G.P. dentist, chiropodists, etc. The home had made sure that people received support from specialist mental healthcare services
30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 6 and had worked with those services to monitor and maintain people’s general and mental health. The home does understand that it is important to find out how good the service they provide people actually is. They want to improve people’s lives and to make the home they live in give them the support and encouragement people need. The company that owns the home carries out regular checks and their own inspections to find out how the home can improve. What has improved since the last inspection? What they could do better:
All care homes need a manager who has the skills, knowledge and values to be able to lead the staff team and to provide the leadership to make sure that standards of service are maintained. The home has not had such a manager for a long time. When the company took over from the previous owners the home did not have a manager and they have found it difficult to find the right person to take charge and to put in place all the changes that the company are trying to achieve. They have put in some temporary arrangements where a manager from another care home that they own provides management support. However, they have to look after their own home and two other small homes as well. This has been a difficult task and the manager has been available to people and the staff team. However, the increase in the number of areas that the home has to improve has shown that a permanent manager is urgently required. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 7 The company have said that a manager has been appointed but, at the time of the inspection site visit, no one knew when they were going to start. Providing people with a place to live that is attractive, well maintained and furnished has beneficial affects on their health and motivation as well as a positive impact for staff working at the home. Previous inspection reports have highlighted that the house requires investment in refurbishment and decoration to raise its standard. The company did provide the CSCI with plans for refurbishment but these have not started within the timescale they gave. The home has been told that they must provide the CSCI with an updated plan on the refurbishment of the home. Training provides staff with the knowledge and skills they need to support people safely and in accordance to legislation, regulation and good practice guidance. It is the home’s responsibility to show that the staff team have the skills and competence to do the job correctly and in the best interests of the people they support. The home were asked to provide staff training records to be able to check what training the staff team had completed. Despite this only two staff training records were available and so there was insufficient evidence to show that the staff team had the required training or vocational qualifications. There was a number of incidences that caused concern in respect to staff training and competence. The first was how the medication training some staff were provided did not include important elements of the medication administration system such as the use of medication administration records, the use of medication prescribed ‘as required’ (PRN) and no information about the actual medication that the people they support use. The training was described as ‘rushed’ and involved giving out ‘lots of leaflets’. The way staff prompt and encourage people should show respect and maintain people’s dignity. It was found that staff, at a meeting of people who live at the home and another care home owed by the company (next door to the home), had raised the issue of individual’s personal hygiene in front of the other people at the meeting. The use of house meetings does not appear to be the appropriate place for staff to discuss these issues and brings into question the values and competence of the staff. Supporting people to take up new and meaningful activities is a key role of the home and the staff team. People had spoken to staff about their ambitions and activities that they wanted to try. When asked about this role one member of staff stated that it was the manager or the persons’ social worker who should do this and staff do not get involved as it was ‘not part of our thingy’. The role of staff in supporting people to find information and opportunities has been raised in previous inspection reports. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 8 An essential part of maintaining peoples’ general and mental health is foe the home to have a clear and accurate medication administration system. This makes sure that people are receiving the medication they need in the right way and that it is all recorded accurately. It was found that the way that the home manages and records the medication had deteriorated. The deficiency in the medication training has been raised, but in addition to this, it was found that several areas of recording medication administered, delivered and returned to the pharmacist was incorrect and there was no recorded way of regularly checking that the right amount of medication had been given. These issues have all been raised with the home and they were told to make the changes needed. 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. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 9 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 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home have the systems in place to make sure that people’s needs are assessed prior to living at the home. EVIDENCE: The home has a referral process for when the home has a vacancy. This could be from a purchasing authority or internally from another of the main company’s homes and services. The home had been provided with relevant pre-admission assessment information from the purchasing authority prior to coming to live at the home. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported and encouraged to make decisions that affect their lives. However, the care planning and risk assessment systems do not fully reflect people’s needs/goals. EVIDENCE: People had an individual care plan that detailed aspects of personal, social and health care needs and provided brief information on how their needs would be supported. The sample care plan seen had been originally completed in June 2004 with the involvement of the person and their representative and/or care manager. Since being developed the care plan was reviewed in October 2005 and in July 2006. There was no evidence that people had been involved in this review of their care plan and support. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 12 Through discussions with a person it was found that not all their expressed goals had been identified in their care plan even though staff were aware of the activity that the person wanted to do. Care plans must identify fully people’s holistic goals. It is recommended that the home develop and implement a more person centred planning approach to how people identify their own needs, goals and the help they need to achieve them. The home does encourage and support people to make decisions and choices about their own routines and the opportunities they want to participate in. Relevant information and support is provided to help people make these judgements and choices. Any restriction of choice in terms of activities or environments is only implemented in response to identifying a risk situation and assessment. One person talked about decisions being made regarding his future that he needed support in making his own views heard. It is recommended that people are given information regarding local advocacy services and are supported to actively access those services when they need them. The home still uses a standard format to look at situations, events and behaviour that may cause a risk to people’s wellbeing. Once identified, the home developed support guidance for staff in how to minimize those risks. The home has a system for recording and reporting incidents and information about situations and events that have happened that could be seen as a risk to people or to staff. Evidence was seen of records where a clear identified risk was raised. It was found that these records had not been passed onto the management team and there was no evidence of any response or risk assessment. The home must review its systems for reporting and recording incidents to ensure they are being followed and protect people and staff. The home must review its risk assessment systems to ensure that changes in people’s behaviour or risk situations have been fully identified, assessed and clear and relevant support guidance is available to staff. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People do have the opportunity to take part in social, leisure and community based activities. Relationships with family and friends are supported and people’s routines are based on their own needs. People are able to decide their own menu choices. EVIDENCE: People living at the home receive support on a 1:1 basis at set times during the week. The aim of this support is to enable people to take part in activities that are meaningful and useful for them. This could be social and leisure activities or skills development, such as education or employment. People described the activities that they enjoyed and participated in. These included taking part in social and leisure activities and being supported to access the local community facilities. These activities were briefly recorded on an activity sheet.
30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 14 A person living at the home had expressed an interest in finding some type of employment or voluntary job. They had raised this with the staff team and had been mentioned to the inspector at previous inspection site visits. There was no reference to this aim in the persons care plan and it appeared, from talking to staff, that it was not clear who had the responsibility of working with the person to help them find a suitable placement. The home must ensure that people are given the information and the support they require to access meaningful activities. People are encouraged and supported to maintain and develop links with their families and friends based on people’s own wishes. People usually set their own routine in terms of the activities that they participate in. There are no rigid routines for meals or other domestic tasks and there is some flexibility in the support provided to support them. People living at the home can be independent in the community and are able to decide for themselves what they want to do. Meals are determined by people themselves and their own personal choices and preferences. The home does provide support and guidance regarding healthy diet choices. Mealtimes are flexible and are taken when it suit people and not the home. There was a reasonable stock of food in the home. 30 Newland Street DS0000021707.V309376.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People are supported to maintain their personal and healthcare needs. However, the medication administration system is unsafe. EVIDENCE: People living at the home were independent in meeting their personal care needs and received prompting and encouragement from the home to maintain this. People’s general and mental health was supported through the staff teams knowledge of a person’s behaviour and triggers for ill health and supported people to access general and specialist healthcare providers when required. Staff were asked about the training they had received in the administration of medication. From the description it appeared that the training did not include the actual medication prescribed to people at the home, the use of medication administration records, medication prescribed ‘as required’ (PRN) and was described as rushed. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 16 Staff must receive suitable medication training to ensure that they are competent and that the medication administration system is safe. It was found that the administering guidance for PRN medication was inconsistent with some medication having no guidance at all. The home must ensure that the medication administration system is safe through the recording of clear and detailed guidance in the administering of PRN medication. It was found that the recording of the time of administering a PRN medication was incorrect. It was also found that the medication returns book had not been signed by the pharmacy and had signatures from the staff missing. The home must ensure that the recording for the medication administration system is correct at all times. It was also found that the home did not undertake any formally recorded auditing and monitoring of the medication administration system. The home must develop and implement a clearly recorded auditing and monitoring system to ensure the safe administration of medication. 30 Newland Street DS0000021707.V309376.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 at least once during a 12 month period. 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. Although people are aware that they can raise their concerns and the home does not have the procedures and practices in place to fully protect people. EVIDENCE: The home had a complaint policy and procedure and a copy of the MultiAgency Protection of Vulnerable Adults. Staff would receive training with regards the protection of vulnerable adults through the Induction Programme and if they had undertaken the NVQ Level2 qualification. Both the people who live at the home can express themselves fully and would raise their concerns and worries with the staff or management team. However, it was unclear if people understood whom they could talk to if their concern was about a member of staff. It was also found that the home had been using a high level of agency staff and a comment was made that people would be worried to talk to staff that they did not know. People must be provided with clear information on the different ways they can raise their worries and concerns. 30 Newland Street DS0000021707.V309376.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home was generally clean but did not provide a homely and comfortable environment. EVIDENCE: The last two inspection reports have highlighted the poor standard of the maintenance, decoration, fixtures and fittings of the home. The company that own the home (Southfields Care Homes Limited T/A The Regard Partnership Limited) had provided the CSCI with plans for the refurbishment of the home. Some work had been carried out to address repairs that affect the health and safety of people living at the home. Some new furniture had been purchased and some decoration had taken place. People had been consulted over the choice of decoration for their bedrooms. However, the house was still poorly decorated, fixtures and fittings were of a poor quality and a number of areas needed repair and replacement. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 19 The home must undertake an audit of all the refurbishment, repairs and replacements required throughout the house. An action plan for carrying out this work must be provided to the CSCI with clear timescales for action. It was also found that the central heating boiler had been out of action for almost three months. The home must have suitable and sufficient heating. The previous inspection report recommended that the home fully consult and take into account people’s choices and decisions in the refurbishment of the home and that evidence of this consultation should be documented. There was no documentary evidence that this was happening. The laundry facilities are located in the kitchen area and are suitable for people’s needs. The previous two inspection reports highlighted the need for staff to have the required training in food hygiene. Some staff working at the home did not have the required training or needed updating. The requirement was therefore reiterated. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has the policies, procedures and practices to make sure that staff are safe to work with vulnerable people. However, the home can not show that the staff team have the skills and competence required to support people’s needs. EVIDENCE: The Pre-Inspection Questionnaire (PIQ) the home were asked to complete prior to the inspection site visit did not contain any information regarding which staff had achieved a NVQ Level 2 qualification. At the inspection site visit the home were only able to provide training records for two of the staff team. Therefore, there was insufficient evidence to show that people were being supported by staff who are competent and qualified in their role. The home must provide the CSCI with written evidence that people are supported by a suitably qualified and competent staff team. Staff support people in all aspects of their lives. The way they prompt and encourage people should show respect and maintain people’s dignity. It was
30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 21 found that staff, at a meeting of people who live at the home and another care home owed by the company (next door to the home), had raised the issue of individual’s personal hygiene. The use of meetings does not appear to be the most appropriate place for staff to discuss these issues. It is recommended that staff are made aware of their role in maintaining the respect and dignity of people living at the home. Staff files had been previously sampled to assess whether all the required checks and documentation required through the recruitment process had been obtained. Files were seen with completed application forms, references received and a contract of terms and conditions. The home procedures for obtaining POVA First checks had been changed to reflect current practice guidance. Each member of the staff team should have a training plan that sets out the training they have undertaken and those events planned. The training audit provided by the home was not up-to-date, as half the staff on the audit did not work at the home anymore. In addition, only two of the staff training records were made available at the inspection site visit. Therefore, it was not possible to establish whether the staff team had the training, skills and knowledge required to fully support people’s needs. The home must provide the CSCI with written evidence that people are supported by a staff team who have received the necessary training, skills and knowledge. The previous inspection record recommended that the home look at providing staff with a number of paid training days. The home had acted on this recommendation. The home had a set Induction Programme for all new members of staff. It was recommended that the home provide the CSCI with their Induction Programme to show that it met the Skills for Care Induction Modules. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has the systems in place to seek peoples’ views on the quality of the service they received. The management provision of the home is not sufficient to effectively manage the home and the home does not have all the systems and practices in place to maintain people’s health and safety. EVIDENCE: At the time of the inspection site visit the home still had no manager. The company had made arrangements where a manager from another of their care homes was providing management cover alongside other members of the management team. The covering manager was also taking responsibility for two other small care homes. They spent a portion of their time at the home and were available for staff to call and to deal with ongoing situations. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 23 The home stated that a manager had been appointed but there was no confirmation when they would be starting work. However, as a number of the previous requirements had not been fully addressed and further areas were identified during the current inspection process the home could not show that the management arrangements provided the leadership and direction that the home requires to deal with the issues raised. The home must appoint a manager who is fit to manage a care home. The home has an established system of quality assurance undertake by the company’s Quality Manager. This involves regular regulation 26 visits to the home and undertaking ‘mock’ inspections to assess how the home is meeting the National Minimum Standards. The home also undertake an annual ‘Satisfaction Survey’ to gain the views of the people living at the home, relatives, carers and other relevant professionals. The home stated that a quality audit had recently been undertaken but they had not yet received the results. It is recommended that the home provide the CSCI with a copy of the recent quality audit. A fire log is maintained for visual checks and fire drills. Fire, gas and electrical equipment was being serviced on an annual basis. The home’s PIQ stated that the Control of Substances Hazardous to Health (COSHH) needs to be reviewed. The home must ensure that all risk assessments, relating to the health and safety of people and staff, that require an annual review are undertaken. 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 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 1 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 1 X 3 X X 2 x 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Care plans must identify fully people’s personal goals. The home must evidence that people are fully involved in the review of their individual care plan. The home must review its systems for reporting and recording incidents to ensure they are being followed and protect people and staff. The home must review its risk assessment systems to ensure that changes in people’s behaviour or risk situations have been fully identified, assessed and clear and relevant support guidance is available to staff. 3 YA12 16 The home must ensure that 01/11/06 people are given the information and the support they require to access meaningful activities. Staff must receive suitable 01/11/06 medication training to ensure that they are competent and that the medication administration system is safe.
DS0000021707.V309376.R01.S.doc Version 5.2 Page 26 Timescale for action 01/11/06 2 YA9 13 01/11/06 4 YA20 13 30 Newland Street (Timescale of 1/06/06 was not met) The home must ensure that the medication administration system is safe through the recording of clear and detailed guidance in the administering of PRN medication. The home must ensure that the recording for the medication administration system is correct at all times. The home must develop and implement a clearly recorded auditing and monitoring system to ensure the safe administration of medication. 5 YA23 13 People must be provided with clear information on the different ways they can raise their worries and concerns. The home must undertake an audit of all the refurbishment, repairs and replacements required throughout the house. An action plan for carrying out this work must be provided to the CSCI with clear timescales for action. 01/11/06 6 YA24 23 01/11/06 7 YA30 13 8 YA32 18 9 YA35 18 The home must have suitable and sufficient heating. All the staff team must have 01/11/06 undertaken food hygiene training. (Timescale of 31/12/05 and 01/06/06 was not met) The home must provide the CSCI 01/11/06 with written evidence that people are supported by a suitably qualified and competent staff team. The home must provide the CSCI 01/11/06 with written evidence that people
DS0000021707.V309376.R01.S.doc Version 5.2 Page 27 30 Newland Street 10 11 YA37 YA42 8 13 are supported by a staff team who have received the necessary training, skills and knowledge. The home must appoint a manager who is fit to manage a care home. The home must ensure that all risk assessments, relating to the health and safety of people and staff, that require an annual review are undertaken. 01/11/06 01/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It is recommended that the home develop and implement a more person centred planning approach to how people identify their own needs, goals and the help they need to achieve them. It is recommended that people are given information regarding local advocacy services and are supported to actively access those services when they need them. It is recommended that the home fully consult and take into account people’s choices and decisions in the refurbishment of the home. Evidence of this consultation should be documented. It is recommended that staff are made aware of their role in maintaining the respect and dignity of people living at the home. It was recommended that the home provide the CSCI with their Induction Programme to show that it met the Skills for Care Induction Modules. It is recommended that the home provide the CSCI with a copy of the recent quality audit. 2 3 YA7 YA24 4 5 6 YA32 YA35 YA39 30 Newland Street DS0000021707.V309376.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 30 Newland Street DS0000021707.V309376.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!
