Inspection on 08/09/05 for 4 Maer Lane

This inspection was carried out on 8th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 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 23/02/06

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 Unannounced 8 September 2005 09:00 th 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 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 Stationary 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 E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 4 Maer Lane Address Market Drayton, Shropshire, TF9 3AL Telephone number Fax number Email 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 698093 Trident Housing Association Cheryl Pauline Sparkes Care Home 10 Category(ies) of Learning Disability (9) registration, with number of places Learning Disability over 65 years (1) 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 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. Date of last inspection 12th October 2004 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. 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 amemnities, transport and relevant support services. Ms Cheryl Sparkes is the Registered Manager and has been employed at the home since October 2001. She is a Registered Nurse for Mental Handicap (learning disabilities) and holds a BA (Hons) in Economics. She is currently working towards a Registered Managers Award. Ms Sparkes is line managed by Ms Dalvinder Kaur who has recently been appointed as the Area Manager. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 4 Maer Lane is a home for people with learning disabilities and a range of complex needs and behaviours that may challenge. The home is registered for ten people to include one person over the age of 65. At the time of this inspection the home had no vacancies. The inspection was unannounced and commenced at 09.00 and lasted five hours. On arrival to the home eight services users were present with four people later being taken out for the day at the Safari Park. Two service users were abroad on holiday supported by two members of staff for the week. The inspection was carried out by talking with four service users, the agency manager, and three staff on duty, observing activity in the home and examination of a number of records. The service users, agency manager and the staff on duty were most welcoming and co-operated fully throughout the inspection. The purpose of this unannounced inspection was to review the progress made by the home since the last announced inspection undertaken on the 12th October 2004 by Ms Sue Jordan, Regulation Inspector. Eleven requirements and seven recommendations were made. A number of these have yet to be met. No formal complaints have been referred to the Commission of Social Care Inspection since the service was last inspected. One complaint was found recorded in the homes complaint book dated 26.01.05 however the action taken and outcome of the complaint was not recorded. One referral has been made to adult protection and a level II meeting was held on 04.07.05. Appropriate action was taken by the home and the case is now closed. What the service does well: The people living at Maer Lane are supported by a committed staff team who strive to meet the individual needs of the people accommodated. People are supported to access their local community and partake in activities. Service users continue to lead active lives and access a variety of leisure activities within the community. Service users are supported to pursue their own interests and hobbies. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: 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 E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 8 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 standard(s) 1 and 5 Service users are not provided with sufficient information about what’s included in the homes fees and any additional costs to be met by the individuals receiving a service. EVIDENCE: Two requirements were made at the previous inspection for the Service User Guide and contract to contain more information as to what is included in the fees and what the service users may be expected to contribute. The Statement of Purpose and Service User Guide available at the home has not been reviewed and updated since the last inspection. The agency manager stated that she has seen documentation regarding the provision of payment towards a holiday and although payment is now in place this is yet to be documented in the contract between the organisation and each service user. The recommendation previously made for the manager to send a copy of the Statement of Purpose to the service users’ families and/or significant others is yet to be met. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 9 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 standard(s) 9 Service users are enabled to take responsible risks however risk management strategies require further development and review. EVIDENCE: A requirement was made at the previous inspection for more evidence that risk assessments are regularly reviewed. Individualised risk assessments were seen on the two care files selected. Although risk assessments have been developed for numerous activities that individuals engage in, it is considered that the assessments require further development generally. It was established that only the senior care officer has received training in risk management and the remainder of the care staff responsible for undertaking risk assessments have not received any appropriate training to support them with this process. A number of risk assessment seen require updating. Risk assessments were available to support the service user holidays and these were seen and agreed by the agency manager in preparation for the holiday. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 10 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 standard(s) 14 and 17 Service users are supported to lead full and active lives. People living at the home are offered a varied, well balanced diet, which takes into account individual preferences and any special dietary requirements. EVIDENCE: £300 per service user, per year is allocated to each service user towards the basic cost of a seven-day holiday or equivalent. At the time of this inspection two service users were on holiday in Jersey supported by two members of staff. Three other service users have enjoyed a holiday in Wales; two in Gurnsey and a further holiday is planned for Blackpool. In addition to this people living at the home have also accessed a variety of day trips through a local tour operator, the homes own transport and a vehicle provided for an individual through the motorbility scheme. On the day of the inspection four people were supported to visit the West Midlands Safari Park for the day. Service users remaining at the home were engaged in in-house activities. The agency manager reported that activity assessment sheets have been developed to ascertain preferred activities enjoyed by individuals. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 11 The inspector joined the four service users, three staff and the agency manager for lunch. The mealtime was relaxed, unrushed and service users requiring support with their meals were assisted appropriately in a discreet and sensitive manner. The menu seen during the inspection appeared well balanced taking into account individual preferences and any special dietary requirements. Service users who are able to assist with meal preparation and catering tasks are promoted to do so wherever possible according to their needs. A vegetable garden has been developed and service users are supported to grow their own fresh produce for the home. Records seen and discussions held with the staff on duty evidenced that service users regularly enjoy having meals out. At the time of the inspection the dishwasher was reported to be broken and this had been actioned for repair or replacement. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 12 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 standard(s) 20 The home has a safe system of managing medication however the current procedure for the monitoring of controlled drugs requires review. EVIDENCE: The review of records and observations made evidenced that the medication administration procedures appeared to be satisfactory at the time of the inspection. It was reported that all service users are currently prescribed medication and that individuals are regularly reviewed by their general practitioner who visits the home every six weeks in addition to the Consultant Psychiatrist. The home has the appropriate storage for controlled drugs and a register. A bottle of Tamazepam dated 12.11.03 was found in the controlled drugs cabinet. It was reported that the person for whom they are prescribed for was on holiday and very rarely requires such medication. The inspector was unable to check the tablets against the records held for the individual as the controlled drugs register and the medication administration record had been taken by the staff supporting the person on holiday. It was reported that the only people with access to controlled drugs are the designated shift leaders. The home utilizes the NOMAD medication system and a chart was seen displayed in the office indicating the staff members who have received training 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 13 from Boots Chemist and the in-house assessments undertaken by the manager. A protocol is in place for the administration of PRN medication. The homes medication policy was not reviewed on his occasion. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 14 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 standard(s) 22 and 23 The home has a complaints procedure in place and procedures to protect service users from abuse. EVIDENCE: Since the last inspection no formal complaints have been received by the CSCI in relation to the service however the CSCI did recently receive a duty call from a member of the public with a concern. The person was advised in the first instance to contact the homes manager. The inspector shared details of the concern with the agency manager who stated that she has not received any verbal or written concerns to date. The home has a complaints procedure in place, which is also available in a format appropriate to the needs of the people living at the home. One entry was seen recorded in the homes complaints book dated 26.01.05 however the investigation, action taken and outcome of the complaint had not been recorded. One referral has been made to Adult Protection following an incident of 28.06.05. A level II Protection of Vulnerable Adults (PoVA) meeting was held on 04.07.05. Appropriate action had been taken by the home and the case is now closed. The home continue to closely monitor the situation and the agency manager reported that a referral to psychology is to be made following a further incident involving a staff member. It was reported that eight staff have completed application forms to attend training on the local adult protection policy and procedures. It was reported that all but one person has a bank account with statements forwarded to the home monthly. Financial records held for three service users were checked by the inspector and found accurate against the monies held. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 15 Records seen evidence that two members of staff sign all financial transactions and weekly audits are undertaken by the agency manager. Discussions held indicate that staff have not received training on the local physical intervention policy and procedures (TPI). 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 16 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 standard(s) x EVIDENCE: The intended outcomes for Standards 24,25,26,28,29 and 30 were not reviewed on this occasion. No requirements were made as a result of the last inspection. The recommendation made at the previous inspection for the kitchen and dining room to be repainted has been actioned and colour schemes chosen following consultation with the service users. It was reported that colour schemes have also been chosen for the reception area, main corridor and the main lounge. The agency manager reported that she is awaiting confirmation from the finance department and senior managers before works can commence. During the inspection the dining room windows overlooking the main road were being measured up for blinds in order to provide service users with greater privacy and security for waking night staff. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,35 and 36 Service users are supported by an enthusiastic and committed staff team who strive to meet the needs of the people accommodated at the home. EVIDENCE: A requirement was made at the previous inspection for systems to be put into place to ensure that the staff have the training, information and supervision necessary for them to understand and deliver appropriate and valued care to the service users, including the management of behaviour. Discussions held with the agency manager evidenced that the home is working towards this. It was reported that the agency manager and senior care officer have had the opportunity to review personnel files and allocated staff supervisions. The paperwork for Personal Development Reviews has recently been amended and managers provided with the new paperwork to be completed with all personnel by 31.10.05 and submitted to head office by 07.11.05. As previously stated in Standard 23, it was reported that staff have not yet accessed the local Training in Physical Intervention (TPI). A recommendation was made at the previous review in relation to NVQ training requirements. Discussions held indicated that only 23 of the team currently hold an NVQ award. Three staff are currently undertaking the award. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 18 The recommendation made for a second senior care officer to be appointed to assist the manager with her duties is now met. It was reported that the home has very recently appointed a deputy manager who will take up the new position very shortly. The management team will then consist of a manager; a deputy and senior care officer. It is positive to report that the home is fully staffed and that core agency staff cover leave and sickness. The current team consists of eighteen care staff. Due to the size and the layout of the home it is recommended that a domestic member of staff be employed to enable the care staff greater opportunities to provide direct care to the people accommodated. Training records seen during this inspection evidence that staff are not in receipt of all mandatory training at the required frequency. Discussions held and records seen indicate that eleven staff have received training in fire safety, seven staff in first aid and nine staff in food hygiene. All but one member of staff have received training in moving and handling in addition to five staff who have attended training in the use of hoists specific to swimming. The agency manager reported that the organisation has a designated Training Officer based at the Head Office in Birmingham and has arranged a meeting with her on 03.10.05 to review the homes training requirements. In the interim the agency manager has linked into training opportunities available locally through the Joint Training for Adult Community and Health Services. She reported that eight staff have completed application forms to attend training on PoVA, Advocacy, Multi-sensory awareness, mobility aids, depression, dementia and falls and exercise for older people. Staff spoken with reported that they are generally provided with good training opportunities. As previously stated staff supervisions have now been allocated within the management team. Staff spoken with reported that they receive regular supervision and that team meetings are held monthly. Performance Development Reviews for all staff are to be undertaken shortly. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,39,40,41 and 42 The health, safety and welfare of service users and staff is not fully promoted or protected by the safe working systems currently in place. EVIDENCE: The registered manager is absent from post and the home is being temporarily managed by an agency manager, Ms Angela Jones, who has managed the home since 11.07.05. The organisation has kept the CSCI informed regarding the temporary managerial arrangements. Discussions held and observations made evidence that Ms Jones has good leadership and management skills, which were confirmed by the staff on duty. Ms Jones reported that she is well supported by the new Area Manager Ms Dalvinder Kaur who has recently been appointed and commenced duties on 08.08.05. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 20 Discussions held with the Area Manager at the recent inspection of another Trident care home evidenced that the organisation is working towards producing a quality assurance system and that managers have been requested to complete a comprehensive self assessment tool on the homes quality of care and service delivery. The CSCI look forward to reviewing the outcome of this assessment. Following the resignation of the former Area Manager Regulation 26 visits have been undertaken by Ms Jan Round, registered manager of the organisations sister home. It was reported that the newly appointed Area Manager, Ms Delvinder Kaur would now take on the role and forward the required monthly reports to the CSCI. Copies of Regulation 26 reports were available in the home. Two requirements were made at previous inspections in relation to the homes policies and procedures. These requirements were for policies and procedures to be developed, reviewed and amended on topics outlined in Appendix 2 (2nd edition of the NMS, Care Homes for Adults 18-65) and for the manager to ensure that the policies and procedures are specific to the staff team and service users accommodated at Maer Lane. It was reported that the homes policies and procedures remain the same and that the only revised policy and procedure received since the agency manager has been in post is the health and safety policy. As identified throughout the report the home record keeping systems require further development to ensure that records required by regulation for the protection of service users and for the effective and efficient running of the home are accessible, maintained, up to date and accurate. A requirement was made at the previous inspection for the registered manager to ensure so far as is reasonably practicable the health, safety and welfare of service users and staff. As previously stated the organisation has revised its health and safety policy and evidence was seen that a health and safety audit of the home is undertaken by the manager on a monthly basis and a checklist completed. It was reported that all but one staff member have recently attended moving and handling training. As previously identified earlier in this report there are gaps in all other mandatory training requirements, which need to be urgently addressed. Evidence was seen that the fire alarms are tested weekly however records indicate that the emergency lighting has not been tested since 29.04.05 and was last tested by contractors on 30.09.04. The agency manager was unable to locate risk assessments for safe working practices or any service certificates. During the inspection one service user was assisting a staff member with testing of water temperatures throughout the home. The agency manager stated that she is happy regarding the security of the building generally however she has requested blinds to be fitted 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 21 in the dining room to offer privacy and security for service users and staff due to the room overlooking the main road. A contractor visited the home during the inspection to measure up the windows and discuss the requirements with the agency manager. During the inspection both the agency manager and staff on duty shared their concerns in relation to the large open hatch between the kitchen and dining area, which currently presents a safety issue for one service user who has restricted access to the kitchen. The home has an accident book, which is data protection compliant. The manager was advised regarding the appropriate storage of these records. Accident records seen evidence that all accidents are recorded no matter how minor. A requirement was previously made for the organisation to review the present managerial hours, responsibilities and the realistic ability to fulfil all of the expectations of the National Minimum Standards and organisational demands. As previously stated a new deputy manager post has been developed and a person has recently been appointed and is due to take up this position shortly, which will assist with the overall management of this home. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x x 4 x x 3 Standard No 31 32 33 34 35 36 Score x 2 3 x 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 4 Maer Lane Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x 3 3 2 2 2 x E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 23 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 YA1 Regulation 4,5 Schedule 1 Requirement The Service User Guide and Statement of purpose must contain more information as to what is included in the fees and what the service users may be expected to contribute. (Previous timescale of 01.11.04 not met). The contract must state that as part of the basic contract price service users in long-term placements have the option of a minimum seven-day annual holiday or equivalent in order to meet NMS 14.4. (previous timescale of 01.11.04 not met). More evidence is required that risk assessments are regularly reviewed. All areas of risk must be assessed to ensure the safety of the service users. Controlled drugs must be handled according to the requirements of the Medicines Act 1968 and guidelines from the Royal Pharmaceutical Society of Great Britain. The complaints book must provide details of how a complaint has been investigated, action taken and the outcome. Timescale for action 24.10.05 2. YA5 5c 24.10.05 3. YA9 13 (4)(b) 14 (2) 24.10.05 4. YA20 13 (2) With immediate effect 5. YA22 22 (8) With immediate effect 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 24 6. 7. YA32 YA35 18 (a) 18(1) 8. YA40 12,13,16, 17,18,19 9. YA40 12,13,16, 17,18,19 10. YA41 17 11. YA42 12,37 12. YA42 13 (4) 13. YA42 12,13(4) (c)13(6) 50 of the care staff must have achieved NVQ 2 or above by 31.12.05. The home must have a training and development plan, dedicated training budget with individual training and development assessments and profiles. Policies and procedures must be developed reviewed and amended on topics outlined in Appendix 2 (2nd edition of the NMS, Care Homes for Adults 1865). (Previous timescales not met). The manager must ensure that policies and procedures are specific to the staff team and service users accommodated at Maer Lane. (Previous timescale of 01.12.04 not met). All records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date, accurate and available for inspection. The registered manager must ensure so far as is reasonably practicable the health, safety and welfare of service users and staff. Risk assessments must be developed for all safe working practices stated in NMS 42.2 and 42.3 and assessments must be accessible to all staff. All staff must receive mandatory training in safe working practices at the required frequency. 31.12.05 01.11.05 01.11.05 01.11.05 01.11.05 With immediate effect 24.10.05 01.11.05 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 25 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. Refer to Standard YA1 YA33 YA33 Good Practice Recommendations It is recommended that the manager send a copy of the Statement of Purpose to the service users’ families and/or significant others. It is recommended that all staff attend training in PoVA and the local physical intervention policy and procedures (TPI). It is recommended that staff responsible for compiling risk assessments receive training to assist them in the process. 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn 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. Extracts may not be used or reproduced without the express permission of CSCI 4 Maer Lane E56 S20766 Maer Lane V220172 UAI 080905 Stage 4.doc Version 1.30 Page 27 - 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!