Inspection on 23/02/06 for 4 Maer Lane

This inspection was carried out on 23rd February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4 Maer Lane 09/07/08

4 Maer Lane 24/07/07

4 Maer Lane 24/05/06

4 Maer Lane 08/09/05

4 Maer Lane 12/10/04

4 Maer Lane 06/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 4 Maer Lane Market Drayton Shropshire TF9 3AL Lead Inspector Rebecca Harrison Announced Inspection 23rd February 2006 10:00 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 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 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 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. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 4 Maer Lane Address Market Drayton Shropshire TF9 3AL 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) 01630 698092 cheryls@trident_ha.org.uk Trident Housing Association Care Home 10 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (1) of places 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The manager must demonstrate that the home is able to meet the individual needs of the older person accommodated through the provision of training and care planning documentation. 8th September 2005 Date of last inspection Brief Description of the Service: 4 Maer Lane is a purpose built residential home situated in Market Drayton, Shropshire. The home is owned and managed by Trident Housing Association. The Head Office is based in Birmingham. The home is registered with the Commission for Social Care Inspection to provide accommodation and personal care for a maximum of ten people with a learning disability to include one person over the age of 65. The home opened in July 2001 and offers spacious accommodation which is furnished to a high standard. Each service user is provided with a single room with en-suite facility. The home is on the fringe of the local town and provides access to local amenities, transport and relevant support services. Mr Anthony McCool is the Director of Care and Responsible Individual. Ms Angela Jones has recently been appointed as the manager and has yet to apply for registration with the CSCI. Ms Jones is directly line managed by Ms Dalvinder Kaur, Area Manager for Trident. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and commenced at 10.00 and lasted seven hours. The inspection included discussions with service users, staff and managers on duty, observing staff interaction and daily life experiences for service users, case tracking of three people, scrutiny of written records and a tour of the home. The service users, managers and the staff on duty were welcoming and fully co-operated throughout the inspection. The purpose of this announced inspection was to review the progress made by the home since the last unannounced inspection undertaken on the 8th July 2005 when thirteen requirements and three recommendations were made. This inspection identified that a number of these remain outstanding. Since the last inspection one formal complaint has been referred to the Commission for Social Care Inspection and one complaint has been received by the home, which was upheld. One referral has been made under adult protection procedures. Appropriate action was taken by the home and the case since closed. What the service does well: It is evident that the people accommodated at this home are supported by a committed and dedicated team of staff who are familiar with the individual needs of the people in their care. Discussions held with staff and observations made demonstrate that service users are provided with good opportunities to access their local community on a regular basis. Staff reported that they are well supported by their managers, that the organisation is a good company to work for and that all staff work well as a team. Although the home is carrying a number of vacancies it was reported that a recruitment drive is to scheduled to take place shortly. Despite these vacancies it is positive to report that the home continues to use ‘core’ agency staff that the service users are familiar with and have developed positive working relationships with. Discussions with an agency staff member on duty indicated that he had a good understanding of the needs of the people accommodated and enjoyed working as part of the team. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Discussions held with staff on duty and observations made evidence that the support staff have a good understanding of service users individual needs however the record keeping systems currently in place do not provide new or agency staff with sufficient information to ensure people are supported in a consistent manner in line with their preferences and needs. Care planning and risk management systems require more detail and need to be reviewed and updated within appropriate timescales. There has been no change to the décor since the last inspection. Shared rooms, in particular, appear ‘tired’ and in need of redecoration to provide people with a homely, attractive and comfortable place to live. All staff spoken with commented that a domestic member of staff is urgently required to assist with maintaining a clean environment for people to live. Staff shared concerns that although they try to engage service users in basic household tasks as much as ability allows, the size of the home and the diversity of the needs of the service users is having an impact on care delivery. It is evident that staff are very much service user focused and the appointment of a part-time domestic member of staff would enable greater opportunities for support staff to spend more quality time with service users and provide more structured activities. No comment cards were received by the CSCI in preparation for this inspection however the CSCI did receive a telephone call from a person wishing to raise a number of concerns particularly concerning a lack of communication. The care plan of one individual case tracked was not in accordance with the stated outcomes for maintaining contact with family. Although discussions 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 7 held and photographs around the home suggest that the home supports people with maintaining relationships, further work should be undertaken to ensure the families of service users are kept well informed of important matters concerning their relatives. People living at the home have been without the use of a minibus for a period of two months due to a major repair being undertaken. Although discussions held with staff and managers indicate that this has not had a significant impact on people accessing the community due to using other resources, it is evident that a number of staff feel the service users would benefit from a smaller vehicle being provided which would appear less institutionalised and would enable people to access the community on a 1:1 or in small groups. Record keeping systems require further development to ensure that records required by regulation are accessible, maintained, up to date and accurate. 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. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 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 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5 Appropriate procedures are in place that would enable the successful admission of a new service user to the home. EVIDENCE: There have been no new admissions or discharges over the last twelve months therefore it was not possible to assess key standard 2 on this occasion. The home currently has no vacancies. The Statement of Purpose and Service User Guide have been revised following requirements made at the previous inspection. Both documents were found well presented however it is recommended that the guide be developed further using a more person centred approach. Following a requirement made at the previous inspection the contract between the provider and service user has been amended to include the option of a minimum seven-day annual holiday or equivalent in order to meet NMS 14.4. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Current care planning systems need to be improved to ensure staff are provided with the relevant information they require to meet the individual assessed needs of the people accommodated. Staff are sensitive to, and have developed systems to identify what service users like and dislike in order to assist them with decision-making processes. Service users are enabled to take responsible risks however risk management strategies require further development and review. EVIDENCE: Three service user plans were case tracked. Two care files examined were found very disorganised and the information fragmented with staff having to peruse through a number of records to obtain the necessary information for care delivery. Although assessment of need was documented information was inconsistent and did not contain sufficient detail for people to be supported in a consistent manner. A number of observation sheets were not consistent with the identified needs. For example it was identified that a person have a leisure activity plan however the observation record simply stated that the person seems to ‘like to put his coat on and continues to express his needs’. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 11 A further plan identified that the service user is diabetic however it later read the person is borderline diabetic and stated ‘if blood sugar levels read high push fluids and if low give a biscuit’. The files pertaining to a third person were found better organised and the care documentation was more detailed. It was reported that two staff members have recently attended training in person centred planning and that this preferred method of care planning is to be discussed with the team and implemented shortly. Discussions held and records seen indicate that only three people have had their individual plans formally reviewed with family and significant others since the last inspection. Service users have allocated key workers who have a responsibility to compile monthly reports in line with the organisations procedures. Documentation seen on all three files evidence that reports have been recently undertaken by new key workers, however previous reports had not been completed for a number of months previous to this. Discussions held with staff on duty indicate that they would welcome training in care planning and assessment. The families and key workers advocate on behalf of service users living at the home. One person without family has a close friend who maintains contact with the home. It was reported that the services of an independent advocate would be sought if required. Services users are supported with the management of their personal allowances and have individual bank accounts. Due to the change of manager the home has experienced a delay in changing service user bank signatories and therefore this has resulted in other methods being used in the interim. However a full internal audit has been undertaken by the organisation and the situation resolved. Monthly monitoring of residents expenditures are conducted by the manager and these were shared with the inspector in addition to individual financial records, which are maintained by the staff team. Financial records for the three people case tracked were an accurate reflection of the monies held on behalf of service users. Requirements have been made at previous inspections that all areas of risk for individuals be assessed and regularly reviewed. Individualised risk assessments were available for all three people case tracked and it is evident that people are enabled to take responsible risks as part of their lifestyles however assessments require further development generally to ensure service users are fully safeguarded. A number of assessments were found undated, not signed by the person responsible for conducting the assessment and contained insufficient detail in relation to control methods. An assessment developed following a referral to adult protection had not been undated for seven months despite the assessment stating a review date of one week. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 12 Moving and handling assessments seen were insufficient to equip the staff with the necessary information required to safely support people in a consistent and safe manner. For example equipment required just stated hoists, sling etc. It was established that only the senior care officer has received training in risk management. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 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 and 16 Service users have a presence in the local community and their rights and responsibilities are respected in their daily lives. Links and communication with families could be further developed and promoted. EVIDENCE: The intended outcomes for Standards 14 and 17 were assessed and met at the inspection and were not reviewed on this occasion. A number of service users living at the home have high dependency needs however discussions held and observations made evidence that people are provided with opportunities to access local resources within the local community to include day services, the library, church, festivals, shopping and leisure facilities. Leisure and community activities were documented on the care documentation reviewed. The home are looking into providing one person with the opportunity of undertaking some work experience locally in accordance with her wishes. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 14 No comment cards were received by the CSCI in preparation for this inspection however the CSCI did receive a telephone call from a person wishing to raise a number of concerns particularly concerning a lack of communication. The care plan of a person case tracked stated that the person must be encouraged to keep in touch with his relative however the only evidence available was when he received correspondence from a relative in July 2005. A list of family birthdays was documented on the files reviewed. It was reported that visitors are always welcome to visit the home and that service users are able to meet with people in the shared spaces available or in the privacy of their own rooms. Relatives are also invited to attend social events held at the home to include barbeques, parties and Christmas celebrations. The home are working towards compiling an individual DVD of photographs for each family. Observations made and discussions held evidence that service users have unrestricted access to the home with the exception of one individual who due to specific reasons is unable to access the kitchen. Discussions held indicate that staff would welcome the hatch opening be fitted with an appropriate closure due to the distress it causes the person who is not able to access the kitchen. A risk assessment should therefore be undertaken. Staff and managers were seen to interact well with service users and not exclusively with each other. Bedroom doors are lockable; one person requests that his door is locked when he is off site. Risk assessments identify that the remainder of people currently accommodated are unable able to use a key. Throughout the inspection a number of service users were engaged in basic housekeeping tasks supported by support staff. Although meals were reviewed at the previous inspection, following a meeting recently held at a day service meal arrangements have changed with people now receiving a main meal in the evening rather than mid-day. It was reported that this new arrangement allows for the home to monitor food intake more effectively. The meal taken with the service users and staff during the inspection was pleasant with people being provided with a choice of sandwiches. The mealtime was relaxed and people provided with appropriate levels of support. The broken dishwasher has since been replaced. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 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 Service users are supported to access community health provision and other appropriate services according to their individual needs however preference with personal support needs requires greater documentation to ensure consistency and continuity of support for service users. The home has a system of handling, storing and managing medication however all staff require accredited training in the administration of medicines to fully safeguard service users. EVIDENCE: The intended outcome for key standard 20 was assessed and not met at the previous inspection. Preferences and guidelines for personal support was found documented on the care files reviewed. As previously stated information on the one file was more detailed than the other two however records seen generally do not provide staff with sufficient detail to ensure there is consistency and continuity of support for the people accommodated at the home. All three files sampled evidence that the service users general health is monitored and people are supported to access NHS Healthcare facilities. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 16 However dental appointments for two people were found to be overdue but the manager reported that all service users have recently been registered with a new dental practice and are awaiting appointments. Health Action Plans were available with evidence of review. A requirement was made at the previous inspection in relation to controlled drugs. The findings of this inspection evidence that the home has since met this requirement. Staff undertake internal competency assessments for the administration of medicines. It was reported that the reassessment of two staff remains outstanding. Five staff are registered to undertake a distance learning accredited medication training course in March. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 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 The home has a satisfactory complaints procedure and systems are in place to safeguard service users from any potential abuse. EVIDENCE: A requirement was made at the previous inspection that the complaint book provide details of how a complaint has been investigated, action taken and the outcome. The findings of this inspection evidence that the requirement has since been met. A new complaints policy and log record has been developed by the organisation and this was implemented in December 2005. One complaint was found recorded in the homes complaints log, which was substantiated. The CSCI received one formal complaint in January 2006 in relation to the service. The complaint was forwarded to Mr McCool, Director of Care to investigate in the first instance. The investigation was conducted by two senior managers who were based at the home over a two-week period. A comprehensive report of the findings has recently been submitted to the CSCI and one of the senior managers responsible for the investigation attended the inspection to discuss the findings with the inspector. The CSCI is currently reviewing the outcome of both the investigation with the findings of this inspection. A recommendation was made at the previous inspection that all staff attend training in PoVA and the local physical intervention policy and procedures (TPI). It was reported that all but four staff have attended adult protection training and a number have attended physical intervention training and the home are awaiting further dates to be confirmed. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 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 The appearance of the home suggests a lack of investment and therefore does not to provide service users with a homely, attractive and comfortable place to live. EVIDENCE: There has been no change to the décor since the last inspection as evidenced through an environmental tour of the home. Shared rooms, in particular, appear ‘tired’ and in need of redecoration to provide people with a nicer environment to live. A number of tiles in the kitchen require replacement as recommended by the environmental health officer during a visit conducted on 10.01.06. A planned maintenance and renewal programme for the fabric and redecoration of the premises was not available for inspection. The manager confirmed that the home has complied with recommendations made by the fire officer and has a satisfactory fire risk assessment in place. The accommodation is accessible and spacious. The home was found reasonably clean and tidy and free from offensive odours on the day of the inspection however a domestic member of staff is not employed. Discussions held with staff and comments received via a CSCI on-site survey evidence that given the size of the home and the dependency levels of the people accommodated, domestic duties are infringing on care 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 19 duties. Staff reported that they are expected to undertake domestic and cooking duties in addition to their care duties and that staffing levels have reduced of an afternoon following a review of funding arrangements for one individual. The home has procedures for dealing with clinical waste and appropriate risk assessments and COSHH data sheets are in place and a designated staff member responsible for maintaining COSHH. One washing machine was found broken however the repair had been actioned. Staff were seen wearing appropriate personal protective equipment and nine staff have been selected to undertake a distance-learning course in the management of infection control, which is to commence shortly. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 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 and 35 Service users are supported by a committed and dedicated staff team who are sensitive to the individual needs of the people accommodated, however further work to develop individuals in specialist areas related to the service user group could be improved. EVIDENCE: The intended outcome for standards 33 and 36 were assessed and met at the previous inspection. A requirement was made at the previous inspection that 50 of the care staff are qualified to NVQ 2 or above by 31.12.05. The home employs seventeen care staff of who seven hold an NVQ award. Most of these staff hold NVQ awards at level 2 and 3. It was reported that four staff are currently undertaking the award and a further four staff are currently working towards LDAF prior to commencing their NVQ Award. The manager stated that the home has experienced difficultly with getting NVQ work assessed however a new assessor has recently been allocated. A training matrix for mandatory training has been developed and a dedicated training budget in place, however a training and development plan for the team and individual training profiles remain outstanding. The home has sourced some training on older peoples needs. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 21 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): 37,40,41 and 42 The new manager has an understanding of the areas in which the home needs to improve. Limited progress has been made to improve the homes record keeping systems. The health, safety and welfare of service users and staff are not fully promoted or protected by the current systems in place. EVIDENCE: The intended outcomes for standards 38 and 39 were assessed and met at the previous inspection. Outcomes for standards 40,41 and 42 were previously assessed and not met. Ms Angela Jones has very recently been appointed as manager for the home pending satisfactory pre-recruitment checks. She has been temporary managing the home since 11.07.05. Ms Jones reported that she has RGN status and has 35 years experience of working in the care sector to include five 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 22 years as a registered manager of an older persons service. Ms Jones is line managed by Ms Dalvinder Kaur, Area Manager and reported that she has received much support from the organisation whilst temporary managing the home. Staff on duty were complimentary regarding the new managers leadership skills and stated that she is open and approachable. Ms Jones has yet to apply for registration with the CSCI. Requirements have been made at inspections previously undertaken in relation to policies and procedures. It is positive to report that the organisation has recently reviewed these. The requirement for policies and procedures to be service specific remains outstanding however discussions held with the manager evidence that she is very aware that ‘one policy does not fit all’ and would advocate a need for localised policies and procedures as required. This inspection identified a shortfall in record keeping systems as identified throughout this report. Significant improvements need to be made to ensure that records required by regulation for the protection of service users, staff and for the effective and efficient running of the home be accessible, appropriately maintained, up to date and accurate. Since the last inspection the organisation has recently developed and implemented a new health and safety policy. A representative from the home attends health and safety forums, which are held on a regular basis. The manager undertakes a health and safety audit of the home on a monthly basis and the findings are recorded. A weekly maintenance repairs record was also available. Three requirements were made at the previous inspection concerning health and safety matters. Although checks are now being recorded further work needs to be undertaken in relation to risk assessments, moving and handling assessments and staff training in safe working practices. The manager was able to evidence that mandatory courses have been booked throughout March however the given timescale for compliance was 01.11.05. A tracking sheet has been developed to record mandatory training course for all staff. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 X 5 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 2 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X X 3 1 2 X 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 24 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 (1) Sch 3 (1)(b) Requirement Timescale for action 31/03/06 2 YA6 15 (1) 3 YA6 15 (1)(2) 4 YA9 13 (4)(b) 14 (2) Care plans for all service users must be more detailed and contain all aspects of personal, social support and healthcare needs to ensure staff deliver the necessary care required in a consistent manner. Care plans must set out 31/03/06 how current and anticipated specialist requirements will be met. Care plans must be drawn 30/04/06 up with involvement of the service user, where possible together with their family and relevant others as appropriate and formally reviewed at least every six months and updated to reflect changing needs; and agreed changes are recorded and actioned. Service users must be 31/03/06 enabled to take responsible risks within a risk assessed framework, which is a comprehensively DS0000020766.V255122.R01.S.doc Version 5.1 Page 25 4 Maer Lane 5 YA15 15 (1) 16 (2)(m) 6 YA18 12 (3) 15 (1) 7 YA19 13 (1)(a)(b) 8 YA20 13 (2) 18 (1)(c) 23 (2) 9 YA24 10 YA35 18 (1)(c) 11 12 YA35 YA37 18 (1)(c) 8 13 YA41 17 recorded and regularly reviewed and updated. Action must be taken to minimise risks and hazards. The registered person must support service users to maintain family links in accordance with their care plans. The registered person must ensure that service users’ preferences with regard to their care are identified, recorded and regularly reviewed. Service users must be supported to access health checks within the appropriate timescales. All staff responsible for the administration of medicines must receive accredited training. A programme of routine maintenance and renewal of the fabric and decoration of the building must be produced, implemented and records kept. An overall training and development plan must be developed, reflecting individual staff appraisals and profiles and linked to service users’ needs. Each staff member must have an individual training and assessment profile. An application to register the newly appointed manager must be submitted to the CSCI. All records required by regulation must be well maintained, up to date and accurate. DS0000020766.V255122.R01.S.doc 31/03/06 31/03/06 31/03/06 30/04/06 10/04/06 30/04/06 30/04/06 01/04/06 31/03/06 4 Maer Lane Version 5.1 Page 26 14 YA42 13 (4)(c) 15 YA42 13 (6) 16 YA42 12 13 (4)(c) 13 (6) Risk assessments must be developed and implemented for all activities requiring guidance on safe working practice. The outcomes of risk assessments must be made known to, and understood by, permanent and agency staff. All staff must receive mandatory training in safe working practices at the required frequency. 31/03/06 31/03/06 30/04/06 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 2 3 4 5 Refer to Standard YA1 YA1 YA6 YA30 YA42 Good Practice Recommendations It is recommended that the manager make a copy of the Statement of Purpose available to the families of service users. It is recommended that the service user guide be developed further using a more person centred approach. It is recommended that all staff access training in person centred planning (PCP) and plans be developed using a more person centred approach. It is strongly recommended that a domestic member of staff be employed to assist with maintaining cleanliness of the home. It is recommended that staff responsible for compiling risk assessments and moving and handling assessments receive appropriate training to assist them in the process. 4 Maer Lane DS0000020766.V255122.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. 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