CARE HOME ADULTS 18-65
30 Newland Street 30 Newland Street Crumpsall Manchester M8 5RY Lead Inspector
Steve O`Connor Unannounced Inspection 19th December 2006 12:00 30 Newland Street DS0000021707.V324367.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.V324367.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.V324367.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 Post Vacant Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places 30 Newland Street DS0000021707.V324367.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th September 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.V324367.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 September 2006. As the previous inspection process had judged that the home was providing a poor service a meeting was held with the Regard Partnership (the company that own and run the home) on the 13 October 2006 to discuss the ongoing concerns and issued raised in the September inspection report. As a result of this meeting the home was required to provide an Improvement Plan setting out how and when the changes needed to improve the home would be actioned. The Improvement Plan was provided within the timescales set for the home. During the unannounced inspection site visit, on the 19 December 2006, 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. The inspection report of September 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. The previous inspection report from September 2006 should be read in conjunction with this report to gain a full picture of the home. What the service does well:
Through discussions with people, the staff on duty and through observations of their interaction the home showed that it does encourage and support people to try to make informed decisions and choices about both day-to-day and longterm decisions. The relationship between people and staff appeared very genuine and positive with a good rapport and interaction between them. 30 Newland Street DS0000021707.V324367.R01.S.doc Version 5.2 Page 6 People were still 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 peoples’ 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 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 well the home is doing and how it can improve. What has improved since the last inspection? What they could do better:
When people live in a care home they should record and set out clearly in sufficient detail peoples’ needs, goals and the support provided by home to help people achieve them. The previous inspection report highlighted that peoples’ care plans did not fully reflect all there needs and what support they needed. There was also no evidence to show how people had been involved in deciding and agreeing their own care plans. In addition, the previous report found that not all areas of peoples’ life and behaviour that could place them at risk had been identified or guidance developed in how staff should support people to cope with these incidents. 30 Newland Street DS0000021707.V324367.R01.S.doc Version 5.2 Page 7 The home’s Improvement Plan states that they aim to maintain a high standard of care plans and will develop a more person centred planning approach to identify where the home needs to help people. There was no evidence to show that any changes had yet been made to the care plans or risk assessments to fully reflect the support that people needed. 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. As a result of the poor standard of the premises the home were required to provide the CSCI with an Improvement Plan setting out how and when the necessary improvement would be made. The Improvement Plan received by the CSCI on the 30 November 2006 made no reference to how the home were going to do this. Therefore, for the second inspection report running the home is required to 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. Training provides staff with 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 the skills and competence to do the job correctly and in the best interests of the people they support. The need to provide a trained, skilled and knowledgeable staff team has been raised through previous inspection reports. As a result of the concerns in this area the home were required to set out in its Improvement Plan how and when staff were going to receive all the training they require to support people. It was found that staff had not received the additional training in how to manage the medication administration system safely and some staff had still not participated in challenging behaviour training. The Improvement Plan stated that staff would receive appropriate medication and care planning training. However, there was no evidence to show that this had been provided. The failure of the home to provide the medication training was evident when a number of errors and an example of bad practice was found. The home was maintaining a record of medication of the level of medication but it was found that the records were wrong. This meant that the home could not show that people had received the right amount of medication and so placed them at risk. There was no evidence of a formal way of checking that the right medication had been given. 30 Newland Street DS0000021707.V324367.R01.S.doc Version 5.2 Page 8 It was also found that the home were taking medication from the packing supplied by the pharmacist and putting it in empty medication bottles or small plastic money bags to give to a person if they were spending a night away from the home. The home was told that this was ‘secondary dispensing’ and must stop immediately. The Improvement Plan supplied by the home stated that it would provide effective monitoring and training to improve the medication administration system. There was no evidence that this had happened. 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.V324367.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.V324367.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. 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 has the systems in place to make sure that peoples’ 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.V324367.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 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 peoples’ needs/goals. EVIDENCE: The previous inspection report had noted that 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. 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. The previous inspection report required the home to improve the care plans and ensure that people are fully involved in the review. There had been no progress on actioning this and therefore the requirement was reiterated.
30 Newland Street DS0000021707.V324367.R01.S.doc Version 5.2 Page 12 It was 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. No action had yet been taken on this and so the recommendation was reiterated. The home does continue to 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 still recommended that people are given information regarding local advocacy services and are supported to actively access those services when they need them. 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. The records were now all being passed onto the management team and this met the requirement made at the previous inspection. The previous inspection report required the home to 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. Examples of risk assessments and guidance were seen that showed that they did not reflect the actual support staff offered people to deal with the risk. Therefore the requirement was reiterated. 30 Newland Street DS0000021707.V324367.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 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 received 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 have described the activities that they enjoyed and participated in. These included taking part in social and leisure activities and being supported
30 Newland Street DS0000021707.V324367.R01.S.doc Version 5.2 Page 14 to access local community facilities. People will go out on their own and also ask staff to support them in accessing some activities. As the home provides 1:1 support, during the day, there is the flexibility in staffing levels to support this. These activities were briefly recorded on an activity sheet. At the previous inspection 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 still no reference to this aim in the person’s care plan. The home have started to work with people to find out what activities they want to take part in and to record this information. 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.V324367.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 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 still independent in meeting their personal care needs and received prompting and encouragement from the home to maintain this. Peoples’ general and mental health was still 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. The previous inspection report highlighted several concerns with the medication administration system. 30 Newland Street DS0000021707.V324367.R01.S.doc Version 5.2 Page 16 Staff were asked about the training they had received in the administration of medication since the last inspection. Those staff on duty stated that they had not received any additional training. The previous inspection report found that the administering guidance for PRN medication was inconsistent with some medication having no guidance at all. The home were required to ensure that the medication administration system is safe through the recording of clear and detailed guidance in the administering of PRN medication. This had not been actioned. The previous inspection report also found that the home did not undertake any formally recorded auditing and monitoring of the medication administration system. From sampling some PRN medication it was found that the record of quantity and the actual amount of medication was inaccurate. The improvements in the medication administration system had not been made and therefore the requirements were reiterated. It was also found that if a person was going to be away from the home the staff were secondary dispensing medication from its original packaging to unused medication bottles or even small plastic money bags. The staff and manager were informed that this was secondary dispensing and must stop immediately. 30 Newland Street DS0000021707.V324367.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are aware that they can raise their concerns and the home does have procedures and practices in place to 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 Level 2 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. 30 Newland Street DS0000021707.V324367.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): 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, comfortable or safe environment. EVIDENCE: The last three 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) have previously provided the CSCI with plans for the refurbishment of the home but these have changed a number of times. Some work had been carried out to address repairs that affect the health and safety of people living at the home. The broken central heating boiler has been replaced, some new furniture had been purchased for the lounge and most of the communal areas have been re-painted in a single colour. 30 Newland Street DS0000021707.V324367.R01.S.doc Version 5.2 Page 19 However, the house still required areas of refurbishment, was generally poorly decorated, fixtures and fittings were of a poor quality and a number of areas needed repair and replacement. The previous inspection report required the home to 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. The home has not provided the CSCI with this information and therefore the requirement was reiterated. During the visit it was found that there was a trip hazard in the area of the kitchen/utility room. This must be repaired. 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. 30 Newland Street DS0000021707.V324367.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 has the policies, procedures and practices to make sure that staff are safe to work with vulnerable people. However, the home cannot show that the staff team have the skills and training required to support people’s needs. EVIDENCE: The current staff team consisted of four support workers providing two staff on duty from 9:00am to 5:00pm and one staff on duty from 7:00am till 9:00am and 5:00pm till 9:00pm. One staff is on sleep-in duty from 9:00pm to 9:00am. A senior support worker provides supervisory support for the home and the home owned and run by the registered provider based next door. The issue of the size of 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 work shifts at the home. Occasionally, the home does have to use agency staff. The manager stated that more staff had been and were being recruited to increase the size of the staff team.
30 Newland Street DS0000021707.V324367.R01.S.doc Version 5.2 Page 21 The previous inspection report highlighted that the registered provider was to provide the CSCI with evidence to show that the staff team had the skills, training and experience to meet peoples’ needs. It was also recommended to provide the CSCI with evidence that the Induction Programme meets the Skills for Care Induction modules. The Improvement Plan submitted by the home identified that staff need to have the skills to carry out their duties and identified medication and care planning training as well as maintaining training records within the home. This had not been actioned and so the requirement and recommendation were reiterated. From talking to and observing how staff worked with people it was seen that they had a good understanding of peoples’ needs and were positive in the way they describe people. They were asked about the training they had undertaken and confirmed that they had not had any additional medication training and neither staff had fully completed the Challenging Behaviour training. 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. 30 Newland Street DS0000021707.V324367.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. 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 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 sufficient to effectively manage the home and the home have the systems and practices in place to maintain people’s health and safety. EVIDENCE: Since the last inspection report the home had recently appointed a permanent manager. 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.V324367.R01.S.doc Version 5.2 Page 23 The manager was clear that there was a number of areas that needed to be improved and was focusing on developing a consistent and skilled staff team and improving peoples’ environment. They were aware that they needed to apply to become the registered manager. It is recommended that the manager make the application to become the registered manager. 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. A fire log is maintained for visual checks and fire drills. Fire, gas and electrical equipment was being serviced on an annual basis. 30 Newland Street DS0000021707.V324367.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 3 23 3 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 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 2 X 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 3 3 1 X 3 X 3 X X 3 X 30 Newland Street DS0000021707.V324367.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 and support needs. The home must evidence that people are fully involved in the review of their individual care plan. (Timescale of 01/11/06 was not met). 2. YA9 13 The home must review its risk 01/03/07 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. (Timescale of 1/11/06 was not met). Staff must receive suitable 01/02/07 medication training to ensure that they are competent and that the medication administration system is safe. (Timescale of 1/06/06 and 01/11/06 was not met) The home must ensure that the medication administration
30 Newland Street DS0000021707.V324367.R01.S.doc Version 5.2 Page 26 Timescale for action 01/03/07 3. YA20 13 system is safe through the recording of clear and detailed guidance in the administering of PRN medication. (The timescale of 01/11/06 was not met). The home must develop and implement a clearly recorded auditing and monitoring system to ensure the safe administration of medication. (The timescale of 01/11/06 was not met) 4 YA20 13 The home must stop the practice of secondary dispensing of medication. 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. (Timescale of 01/11/06 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. The registered provider must provide the CSCI with written evidence that people are supported by a staff team who have received the necessary training, skills and knowledge. (Timescale of 01/11/06 was not met). 20/12/06 5. YA24 23 01/02/07 6 YA24 13 25/12/06 7. YA35 18 01/02/07 30 Newland Street DS0000021707.V324367.R01.S.doc Version 5.2 Page 27 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 YA24 Good Practice Recommendations 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 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 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 manager make the application to become the registered manager. It is recommended that the home provide the CSCI with a copy of the recent quality audit. 2. YA6 3. YA7 4. YA32 5. YA35 6 7. YA37 YA39 30 Newland Street DS0000021707.V324367.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 30 Newland Street DS0000021707.V324367.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!
