CARE HOME ADULTS 18-65
30 Newland Street 30 Newland Street Crumpsall Manchester M8 5RY Lead Inspector
Steve O`Connor Unannounced Inspection 17th May 2007 10:30 30 Newland Street DS0000021707.V334649.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.V334649.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.V334649.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.V334649.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th December 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. Fees are negotiated on an individual basis with purchasing authorities. 30 Newland Street DS0000021707.V334649.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 December 2006. During the unannounced inspection site visit time was spent talking with people who live at the home, talking to and observing how staff work with people and the recently appointed manager. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. Further documentation was examined on the 18 May 2006 at the manager’s office based at another of the registered providers care homes. The inspection report of December 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. What the service does well:
Through discussions with people, the staff on duty and through observations of their interaction the home showed that it still encourages and supports people to make informed decisions and choices about both day-to-day and long-term decisions. People living at the home were able to explain how they were encouraged and supported to make a major decision about their future. They were clear that the staff and management were not pressuring them or making them do something that they did not want to do. In addition, the home were working closely with the purchasing authority to make sure that people had access to others outside the organisation to talk to and help them in making choices and decisions. The home continues to understand that it is important to find out how good the service they provide actually is. The company that owns the home carries out regular checks and their own inspections to find out how well the home is doing and how it can improve. The manager has recently introduced a new way for people and staff to spend time together, on a regular and ongoing basis, to sit down and talk about how the person feels about the service and to raise any concerns or problems they have. Examples were seen where people had raised issues about the standards of the building environment and the manager had acted upon these. 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
The inspection report highlighted a number of areas that the home was required to take action. These include the following issues, which had been raised in the previous inspection report and have not been adequately addressed. Previous inspection reports have highlighted that the house requires investment in refurbishment and decoration to raise its standard. A tour of the building found that windows and door frames were damaged through wood root and peeling paint. The back yard of the house had broken fencing. Many of the carpets in the home were of poor quality and stained, the kitchen had poor quality and damaged units, damaged tiling and in the utility room was evidence of extensive damp. The bathroom was in poor condition with broken tiles and in need of decoration. The company that manages the home (Southfields Care Homes Limited T/A The Regard Partnership Limited) have been requested in two inspection reports to set out a plan for how they are going to raise the standards of the home that people live in but have not provided the CSCI with any information on how or when they are going to achieve this. 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 7 The home has the responsibility to provide sufficient staff who have the knowledge and skills they need to support people safely and in accordance with legislation, regulation and good practice guidance. It is the home’s responsibility to show that the staff team have those skills and competence to do the job correctly and in the best interests of the people they support. Through discussions with staff on duty and from examining the staff training records it was found that a number of key training areas did not appear to have been provided. For example, even though the staff help support and encourage people to cook their own meals the staff member on duty at the time of the site inspection had not received any Basic Food Hygiene training. There was also no evidence that the staff member had undertaken any Fire Safety or Adult Protection training. The issue of the need to provide staff with the required training had been raised through previous inspection reports and the last report required the home to provide the CSCI with evidence that they were providing this training but no information was received within the timescale given. The last two inspection reports had identified the need for the staff team to undertake further medication training due to the errors found in the medication administration system. There was no evidence that the home had provided staff with this training and this was emphasised through the concerns found in how the home were managing people’s medication. The inspection found that the same errors and poor practice were being carried out despite these issues being raised in the last inspection report and the home’s Improvement Plan stating that they would provide a safe and accurate medication administration system. The home had a clear policy and procedure for helping people to manage their personal finances. The recording system had been seen during previous inspection site visits and found to be clear and accurate. However, it was found on this site visit that the previous manager had introduced their own recording system and that this contained errors and did not reflect the home’s own procedures. It could not be explained why this change had not been picked up through the home’s quality assurance system and was still being used seven weeks after the appointment of the new manager. 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. 30 Newland Street DS0000021707.V334649.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 30 Newland Street DS0000021707.V334649.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): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems were in place to make sure that people’s needs are assessed prior to living at the home. EVIDENCE: There had been no new admissions to the home since the previous inspection. The home had a referral process for when there is 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 the current people coming to live at the home. 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On the whole, the home does understand and provide the support and help that people need on a day-to-day basis. However, this is not always reflected through the care planning or risk assessment systems, which means that the home cannot clearly evidence that peoples holistic needs and choices are being met. EVIDENCE: The previous inspection report highlighted that people’s care plans should fully identify people’s goals and support needs. Evidence was seen that the care plans had been reviewed and updated and contained more detailed information on what support people needed. It also included more information about the people themselves including their details of their likes and dislikes, and activities they like to participate in. 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 11 The previous report also 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. This had not yet been implemented and so the recommendation regarding person centred care planning was reiterated. The manager stated that as the care plans had only recently been updated they had not yet implemented a formal care planning review system to reflect the ongoing and changing needs of people living at the home. They had introduced a ‘Keyworker’ system where a named member of staff would work more closely with a person to regularly review the support they receive and to raise any concerns or changes in their needs. Evidence was seen of the keyworker role and how people were raising issues about the home and what they wanted changing. The home must ensure that they evidence clearly how peoples support and needs are being met and changes are clearly reflected and understood so that people receive the support they need. The home does continue to encourage and support people to make decisions and choices about their own routines, the opportunities they want to participate in and decisions that affect their lives. The people living at the home explained how they were planning to move to another house as they were more independent. They both stated that they were in agreement with the move, had not been pressured and were able to discuss their concerns with the manager and with other people outside of the home. The previous inspection report required the home to review its risk assessment systems to ensure that the support people needed to take risks were supported and managed correctly. The manager stated that all current risk assessments had been reviewed to make sure that they were still relevant. However, this process had not yet been fully recorded or reflected in written risk assessments. It was also found that some areas of support such as people managing their medication and finances needed to be reviewed in terms of risk and the support people needed to manage those risks. 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported and encouraged to make their own choices and decisions about the lifestyle they have and the activities they want to participate in. EVIDENCE: People living at the home explained the activities that they enjoyed and wanted to participate in. They were encouraged to find out about local facilities and events and provided with information to help them make choices about what they wanted to do. Since the previous inspection the staff support levels had changed to reflect that people were much more independent and could decide for themselves what they wanted to do and their own routines. This reduction in support reflected people’s needs and personal goals. 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 13 People were encouraged and supported to maintain and develop links with their families and friends based on people’s own wishes. People living at the home described their friendships and their relationships with the local community. Meals are chosen by people based on their own personal choices and preferences. The home does provide support and guidance regarding healthy diet choices according to people’s health needs. Mealtimes are flexible and are taken when it suits people and not the home. There was a reasonable stock of food in the home. 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home provides support to help people maintain their health and personal care, they have not shown that the medication administration system ensured that people received the medication that they need. EVIDENCE: People’s care plans and risk assessments identified what support and encouragement people needed to maintain their personal and healthcare needs. If people wanted, they were supported to attend health appointments and access to other healthcare services. It is recommended that people’s personal and healthcare needs and support, especially around maintaining their emotional and mental health, be clearly assessed and evidenced using the person centred approach. The previous inspection report highlighted a number of concerns with the management of the medication administration system. There was a lack of guidance on the administration of medication prescribed ‘ as required’ (PRN)
30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 15 and the need for a formal auditing process and to stop the practice of secondary dispensing of medication. Samples of the medication administration records were seen and found that although most administering had been recorded accurately members of staff were not using the correct coding system to reflect when medication had not been taken. No auditing system had been implemented. It was also found that the PRN guidance for administering painkillers had not been actioned, as was required from the last inspection report. It was also found that members of staff staff were still undertaking the practice of secondary dispensing medication when a person was spending the day/night away from the home. In addition, staff spoken to during the site visit confirmed that they had not received any additional medication training since the last inspection. This was reflected in the errors found in the medication administration system. The manager stated that they were aware of the issue and were in the process of introducing a daily and weekly auditing system. 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems were in place to protect people but not all of these systems were being followed which did not ensure that people are safe from financial abuse. EVIDENCE: 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. The manager had introduced a ‘keyworker’ system where staff would spend time with people and discuss any concerns and worries they had. Evidence was seen of when a person raised concerns about the environment of the home and this was recorded, and actions set to resolve the concerns. 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 Level 2 qualification. The manager was able to describe the procedures for responding to concerns around adult protection issues. The home has a clear policy and procedure for managing people’s personal finances. On previous inspection visits these have been sampled and checked for accuracy. During the inspection visit it was found that the previous manager had decided not to use the set recording procedures and had implemented their own
30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 17 records. These did not accurately account for all monies coming into the home and given to people. The current manager did not know why the set procedures had not been followed but stated that they would reinstate the normal recording procedures immediately. The home must ensure that they have the systems in place to accurately record and audit people’s personal finances in accordance with their own policy and procedures to protect people from possible abuse. 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The premises were generally clean but did not provide a homely, comfortable or safe environment for people to live. EVIDENCE: The last four inspection reports have highlighted the poor standard of the decoration, fixtures and fittings of the home. The company that own the home (Southfields Care Homes Limited T/A The Regard Partnership Limited) had previously provided the CSCI with plans for the refurbishment of the home but these have changed a number of times. The house still required refurbishment in several areas and was generally poorly decorated, with fixtures and fittings of a poor quality and a number of areas that needed repair and replacement internally and externally. 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 19 The previous two inspection reports required the home to undertake an audit of all the refurbishment, repairs and replacements required throughout the house. The home has still not provided the CSCI with this information and therefore the requirement was reiterated for a second time. During the visit it was found that electric plugs and extension leads were located on the floor near to mop buckets and the washing machine and could pose a health and safety risk. The home must ensure that the use of extension leads does not pose a risk to people’s health and safety. The previous inspection reports 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 next to the kitchen area and are suitable for people’s needs. 30 Newland Street DS0000021707.V334649.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. 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 does not provide a sufficient staff team that has the skills, training and competence required to support people’s needs. EVIDENCE: The current management team consisted of the manager who divides her time with two other small homes managed by the same company and a deputy manager who has been allocated 8 hours to help the manager with the management of this and the two other homes. The care team should consist of three full-time equivalent support workers providing one staff on duty from 9:00am to 9:00pm. One staff is on sleep-in duty from 9:00pm to 9:00am. This is a reduction in the support hours provided since the previous inspection and had been made in consultation with the purchasing authority and based on people’s actual support needs. At the time of the site visit two members of the staff team had recently left the company leaving one member of staff working permanently at the home. It is recommended that the home follow the POVA guidance for when it is appropriate to make an application to the POVA List. The issue of the size of
30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 21 the staff team was discussed with the manager. To provide cover for training, holidays and sickness, support staff from other registered care homes, owned by the company, also worked shifts at the home. The manager stated that very occasionally the home did have to use agency staff. The manager stated that they were aware of the importance of a stable and consistent staff team and that they were in the process of recruiting new staff for the team. The home must ensure that it has a sufficient staff team to provide the support and understanding that people need. The previous inspection report required the home to make sure that its staff team had the training, skills, knowledge and competence required to support people’s needs. The manager had a training schedule provided by the company that manages the home and included dates for Induction training, mental health, and care planning. They also provided a rolling Induction training programme. The Improvement Plan submitted by the home in November 2006,in response to a previous inspection report, had itself identified that staff needed to have the skills to carry out their duties and identified medication and care planning training as well as the need to maintain training records within the home. However, through discussions with the staff on duty, the manager and sampling training records, kept at another care home the company managed, it was found that staff had not been provided with the medication training required. A staff member spoken to during the inspection visit also stated they had not received any basic food hygiene or first aid training. Samples of staff training logs were seen and showed the training events that staff had participated in. It was noted that a member of staff had no record of Induction, health and safety, moving and handling, Abuse awareness or fire training. Therefore there was no evidence to show that the home had met the requirement for ensuring its staff had the skills and knowledge required to support people living at the home and was reiterated. The manager had started to undertake staff supervision to identify the training needs of the staff team. Evidence was seen of the training that had been identified as needed and these events were being booked with the main company’s training team or an external provider. The manager also stated that they were going to carry out more in-house training sessions for the staff team. It is recommended that the home undertake an audit of staff training to establish the gaps in training and need for refresher training was required. Staff files had been previously sampled to assess whether all the required checks and documentation required through the recruitment process had been 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 22 obtained. Files had been seen with completed application forms, references received and a contract of terms and conditions. 30 Newland Street DS0000021707.V334649.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 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management team and operational systems were in place to seek people’s views of the service and to maintain their health and safety. EVIDENCE: Since the last inspection report in December 2006 the manager, who had only recently been appointed at the time, had been asked to leave the service. The current manager had been in post for around 7 weeks. The manager had responsibility for two other small care homes all based within a short distance of each other. Due to the layout of the home the manager was not based at the home but visited every day. 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 24 The current manager had several years of management experience including being a registered manager at another care home. They had experience in working with people with learning disabilities, autism and mental health issues. The manager had gained the Registered Managers Award in 2003. They were also developing their knowledge and skills through further study. They stated that they were aware of the need to apply to become the registered manager and had the relevant documents to complete. The manager must submit an application to become the registered manager of the home as required by the Care Homes Regulations 2001. The manager stated that they were aware of the issues and concerns regarding the home that have been identified through previous inspection reports. They stated that were supported to achieve these changes through her senior management but acknowledged that she had not had any formal supervision herself. It is recommended that the manager have access to regular and ongoing formal supervision to ensure that the managers own development needs and the progress in developing the service are clear and defined. 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 manager was asked whether the monthly visits had identified the problems and concerns highlighted in this report. The manager stated that the reports she had seen had identified these issues. There were no copies of the visits maintained in the home. Copies of the Regulation 26 visits must be submitted to the CSCI to show that the home is addressing the issues raised in this inspection report. The manager stated that they had introduced a system where each month staff would spend time with each person to find out how they felt about the service and any concerns or problems they may have. Examples of these sessions with people were seen and showed that issues and concerns were being raised and dealt with. A fire log is maintained for visual checks and fire drills. A fire risk assessment had been reviewed. Up-to-date environmental risk assessments had been undertaken in relation to the health and safety of the home. Records for monitoring temperatures of the hot water and fridge/freezer was being maintained. It was found that the gas safety certificate was out of date and action must be taken to remedy this. 30 Newland Street DS0000021707.V334649.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 X 2 2 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 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 2 2 X X 2 X 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 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 YA6 Regulation 15 (2) (b) Requirement Written evidence must clearly show how people’s support needs are being reviewed and changes are clearly reflected in the care plan so that people receive the support they need. The risk assessment systems must be reviewed, and updated where required, to ensure that risk situations have been fully identified, assessed and clear and relevant support guidance is available to staff. Staff must receive suitable medication training to ensure that they are assessed as competent and that the medication administration system is safe. (Timescale of 1/06/06, 01/11/06 and 01/02/07 was not met) The medication administration system must be safe through the recording of clear and detailed guidance in the administering of PRN medication. (The timescale of 01/11/06 and
30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 27 Timescale for action 01/07/07 2. YA9 13 (4) (b)(c) 01/07/07 3. YA20 13 (2) 01/06/07 01/02/07 was not met). A clearly recorded auditing and monitoring system must be implemented to ensure the safe administration of medication. (The timescale of 01/11/06 and 01/02/07 was not met) The practice of secondary dispensing of medication must stop. (The timescale of 20/12/06 was not met). The medication administration records must be accurately completed to show the administration of people’s medication. The procedures and systems for 01/06/07 managing people’s finances must ensure that they accurately record and audit people’s personal finances in accordance to their own policy and procedures to protect people from possible abuse. An audit of all the refurbishment, 01/07/07 repairs and replacements required throughout the house must be undertaken. An action plan for carrying out this work must be provided to the CSCI with clear timescales for action. (Timescale of 01/11/06 and 01/02/07 was not met). The registered provider must ensure that the home is free from hazards that can affect the safety and welfare of people living at the home. Sufficient staff must be available at all times to provide the support and understanding that people need. 4 YA23 13 (6) 17(2) Schedule 4 5. YA24 23 (1) 23 (2) (b) 6 YA32 18 (1)(a) 01/07/07 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 28 7. YA35 18 (1)(a) 8 YA37 9 (1) 9 YA39 24 (2) People’s needs must be 01/07/07 supported by a staff team who have the necessary training, skills, knowledge and competence to meet those needs. (Timescale of 01/11/06 and 27/02/07 was not met). The manager must submit an 01/07/07 application to become the registered manager of the home as required by the Care Homes Regulations 2001, to establish that they are ‘fit’ to manage the home. Copies of the Regulation 26 visits 01/06/07 must be submitted to the CSCI to show that the home is addressing the issues raised in this inspection report. The gas safety certificate was out of date and action must be taken to remedy this. 01/07/07 10 YA42 13(4)(c) 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. Also that the home evidence that people are fully involved in the review of their individual care plan. It is recommended that people’s personal and healthcare needs and support, especially around maintaining their emotional and mental health, be clearly assessed and evidenced using the person centred approach. 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.
DS0000021707.V334649.R01.S.doc Version 5.2 Page 29 2 YA18 YA19 YA24 3. 30 Newland Street 4. 5 6. YA32 YA34 YA35 It is recommended that staff are made aware of their role in maintaining the respect and dignity of people living at the home. It is recommended that the home follow the POVA guidance for when it is appropriate to make an application to the POVA List. It is recommended that the home undertake an audit of staff training to establish the gaps in training and need for refresher training was required. It is recommended that the manager have access to regular and ongoing formal supervision to ensure that the managers own development needs and the progress in developing the service are clear and defined. It is recommended that the home provide the CSCI with a copy of the recent quality audit. 7. YA38 8. YA39 30 Newland Street DS0000021707.V334649.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North West Regional Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU 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
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