CARE HOME ADULTS 18-65
49 King Street Thorne Doncaster South Yorkshire DN8 5AU Lead Inspector
Ms Shelagh Murphy Key Unannounced Inspection 15th March 2007 09:25 49 King Street DS0000044366.V320001.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 49 King Street DS0000044366.V320001.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. 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 49 King Street Address Thorne Doncaster South Yorkshire DN8 5AU 01405 818580 01405 743110 christine.hobson@hesleygroup.co.uk www.hesleygroup.co.uk Hesley Lifecare Services 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) Christine Hobson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users aged 16/17 should not be accommodated where there are other service users over the age of 25. 28th November 2005 Date of last inspection Brief Description of the Service: 49 King Street is situated in the market town of Thorne, approximately 11 miles from Doncaster, and is situated in close proximity to the town centre and is close to public transport, shops, supermarket, post office, and health facilities. It is also close to both motorway (M18 and M62) and Thorne railway station, which provides regular access to Doncaster Goole, and surrounding areas. The property comprises a large detached six - bedroom house, with all bedrooms being on the first floor, and containing en-suite facilities. The ground floor facilities comprise of two separate lounges, a large dining room, conservatory, kitchen, cloakroom and utility room, and an activities rooms. The rear of the house includes a large private garden, with a terrace overlooking the lawned grounds, and private car parking, and there is a secure patio area at the front of the building. The present fees for the service per annum start at: £218,216.00. This is the minimum fee and all fees are based on the individuals support needs. 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a key unannounced inspection conducted by Shelagh Murphy. Prior to the inspection the manager was supposed to complete a pre-inspection questionnaire, however, she stated that this had not been received at the service and therefore relevant information was collated at the time of the inspection. A fieldwork visit took place over seven hours and fifteen minutes. Opportunity was taken to make a tour of the premises, inspect a sample of records including care plans, training records and to speak to the people who use the service, the manager and the staff. In all four of the six service users were interviewed or surveyed, three staff were interviewed and six completed surveys. The inspector wishes to thank the manager and staff for their assistance and time throughout the inspection process. What the service does well:
The people who use the service had their needs assessed prior to being admitted to the home to ensure their needs could be met. People were observed to be offered assistance to make decisions about their everyday lives and this included taking risks in order to develop more independent lifestyles. The staff knew how to meet the service users needs and if asked how they did this, they could tell you in great detail as they had lots of knowledge about individuals. The care plans checked had been reviewed on a regular basis in order to identify any changing needs of the people who lived at the service. Four people who lived at the home were surveyed and they said that the staff support them to make everyday decisions about their lifestyles and gave as examples of this as choosing what they ate for meals, how they spent their money, what activities they took part in during the day and at the weekends etc. One person said, “staff help me to see my family”, “I decide and plan my own weekly timetable”. In order to develop and lead individual lifestyles people were supported to take part in activities of their own choosing which, were age, peer and culturally appropriate. They also accessed some local leisure and other community facilities and were encouraged to maintain appropriate personal relationships with their families, peers and friends. Overall, people were treated with respect as adults and their rights were recognised by staff. People were offered a range of meals to maintain a healthy diet and lifestyle and staff supported them to shop for and prepare meals of their own choosing.
49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 6 People were protected by the medication policy, procedures and practices. The people who live at the home have their views listened to and acted upon. In this way they are protected from harm, abuse and self-harm in order to lead safer lifestyles. People live in a homely, comfortable and safe environment, which was very clean, it was decorated in an informal, cosy and age appropriate manner, which took in to account peoples complex needs. The recruitment policy and procedures protected the people who used the service. Individual staff were offered appropriate specialist and mandatory training at the required frequencies to ensure they remained up to date with good practice issues. People were therefore, supported by committed and competent staff. People benefit from a well managed home. The manager of the home was well liked by both the people who live at the home and the staff team who were supportive of her management. The service users views are taken in to consideration when development of the service is considered, but this is done in an informal manner, therefore it was difficult to evidence the quality assurance system. The people who live at the home are protected by robust health and safety policies and practices. What has improved since the last inspection? What they could do better:
The statement of purpose and service user guides were not up to date and or did not contain all of the information required for service users and carers to make an informed choice about whether to live at the home. People had individual care plans, however, these needed to contain more specific details to meet individuals’ needs. The manager told the inspector that at present service users do not have person centred plans and it is recommended that this model of care and support planning be introduced in
49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 7 the near future to meet peoples needs in the way they, their carers and supporters feel best meets their individual needs. This is also good practice and is advocated in the, “Valuing People” a strategy for learning disability for the 21st century. The manager is also aware that under guidance from the “Valuing People” strategy that all people with a learning disability should have a health action plan by 2005. However, these were being devised but are not yet in place. Recommendations to introduce both of these practices have been made in this inspection report. Overall people were supported by competent staff, however, more staff need to gain the NVQ 2 care awards to ensure that people are supported by appropriately trained and assessed staff. 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. 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had produced an appropriate statement of purpose. The service user guides were not up to date and did not contain all of the information required for service users and carers to make an informed choice about whether to live at the home. People who use the service had their needs assessed prior to being admitted to the home to ensure their needs could be met. EVIDENCE: The home had an up to date statement of purpose, but the service users guides were not both up to date and did not contain all of the information required to meet the regulations. This was an outstanding requirement from December 2005. Three service users files were checked. The assessments checked were all found to be very detailed. They had been devised by a range of appropriate, health, education and social care professionals, to take into account the service users complex needs. The manager said that needs assessments are sought for all service users prior to admittance to the home from a central assessment team and forwarded to 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 10 the manager and staff to ensure peoples needs, can be met before they are offered a placement. 49 King Street DS0000044366.V320001.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 good. This judgement has been made using available evidence including a visit to this service. People had individual care plans, however, these needed to contain more specific details to meet individuals’ needs. People were offered assistance to make decisions about their everyday lives and this included taking risks in order to develop more independent lifestyles. EVIDENCE: The manager told the inspector that at present service users do not have person centred plans and it is recommended that this model of care and support planning be introduced in the near future to meet peoples needs in the way they, their carers and supporters feel best meets their individual needs. This is also good practice and is advocated in the, “Valuing People” a strategy for learning disability for the 21st century. The staff knew how to meet the service users needs and if you asked them how they would tell you and had lots of knowledge about individuals. However, when three care plans were checked, these identified the service users needs
49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 12 but did not state how staff should support people to meet their needs. They needed to contain more detailed information about how, when and who should support people to meet their needs in a person centred way as otherwise this information could not be passed on to others if the staff or service users moved on. The care plans checked had been reviewed on a regular basis in order to identify any changing needs of the people who lived at the service. Two service users said they were able to attend their care plan review meetings and the staff said parents could be invited to review meetings if they wished to attend. Letters to parents requesting their attendance evidenced this. Four people who lived at the home were surveyed and they said that the staff support them to make everyday decisions about their lifestyles and gave as examples of this as choosing what they ate for meals, how they spent their money, what activities they took part in during the day and at the weekends etc. One person said, “staff help me to see my family”, “I decide and plan my own weekly timetable”. Another person said they usually made decisions about what they did each day. The inspector observed staff speaking to people in an empowering manner and asking people to make choices. This was really positive and created an informal but respectful relationship between the staff and service users. As well as supporting people to make decisions about their lifestyles there was evidence on the three files checked, that risks associated with living a more independent lifestyle had been assessed to protect people and the staff who supported them. Examples of this were people going on outings without staff support, supporting people who presented challenges to the service. 49 King Street DS0000044366.V320001.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 good. This judgement has been made using available evidence including a visit to this service. In order to develop and lead individual lifestyles people were supported to take part in activities of their own choosing which, were age, peer and culturally appropriate. They used some local leisure and other community facilities and were encouraged to maintain appropriate personal relationships with their families, peers and friends. Overall, people were treated with respect as adults and their rights were recognised by staff. People were offered a range of meals to maintain a healthy diet and lifestyle. EVIDENCE: Four of the people who lived at the home told the inspector about their individual lifestyles, interests and the activities they enjoyed taking part in. One person told me they had a job at a local supermarket and independently travelled and worked there on a regular basis, others said they enjoyed
49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 14 shopping, attending educational groups at Hesley College and visiting leisure facilities such as the local swimming baths. During the inspection the inspector observed staff supporting service users to go out shopping to buy gifts for Mothers day celebrations, such as cards and flowers. The staff also said that some people had made gifts for their Mothers at the Hesley College pottery group. The people who live at the home told the inspector they are helped to keep in contact with their relatives and friends by phone and one member of staff said one person keeps in contact with their relatives via video link as they have non-verbal communication skills and this aided communication and connection between the person and their parents. Staff said that they phone parents and carers on a monthly basis to keep them up to date with the person’s activities and there was evidence that staff had recorded this on the records checked. Throughout the inspection staff were observed to speak to people with respect and to offer choices in order to enable people to make every day decisions. Those people who did not communicate verbally were seen to be supported using appropriate communication aids. The staff that were surveyed and interviewed were able to list ways in which they supported service users and gave people choices. Four of the people who lived at the home and six staff said that service users chose what they had for their meals and individuals likes and dislikes were recorded. Staff said the people who lived at the home took it in turns to shop for food. They are supported to choose and prepare their own breakfasts and lunches and take it in turn to prepare the evening meals. 49 King Street DS0000044366.V320001.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 good. This judgement has been made using available evidence including a visit to this service. Overall people at the home are offered personal support, and their physical and health needs are met in the way they prefer, however, this needs recording in a person centred manner to ensure all staff are consistent in these practices. People are protected by the medication policy and practices. EVIDENCE: Three of the four people surveyed said the staff supported them with personal care tasks and helped them in a way they felt happy with. One person said they did not need staff to support them. Information about how to offer personal care support to individuals needs to be recorded in more detail in the care plans. (See Standard 6) The manager is aware that under guidance from “Valuing People” a strategy for learning disability for the 21st century, all people with a learning disability should have a health action plan by 2005. However, these are not yet in place Staff explained that service users physical health needs were met via local health services and that health action plans were presently being devised to
49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 16 record and plan how to meet peoples health needs in a more strategic manner. The manager stated that the local GP had not yet signed up to the health action plans but she would expect them to in the near future. The three people case tracked all had an individual medical file, and there was also medical audit sheets. People who live at the home reported that relatives and staff help to support their emotional health needs and for those people for whom it is appropriate they have access to psychiatric and psychology support from staff at Hesley College. The inspector observed staff offering a lot of emotional support to one person throughout the inspection this was offered with tact and professionalism. Only those staff that have received training are allowed to administer medication. The team leader responsible for medication said that none of the people who live at the service have been assessed as able to administer their own medication. A medication round was observed and medication records were checked. The medication sheets contained appropriately detailed information and medication was signed for after administration. There was evidence that some people had had their medication reviewed in the records checked. 49 King Street DS0000044366.V320001.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 good. This judgement has been made using available evidence including a visit to this service. Overall, people who live at the home have their views listened to and acted upon. In this way they are protected from further harm, abuse and self-harm in order to lead safer lifestyles. EVIDENCE: The service had an adult protection policy and procedure and copies of the local safeguarding procedures. It was evident from speaking to two service users that staff listened to and acted upon their views and took action to protect these people from further harm. Staff also reported that another service user had made a complaint about staff misconduct and this was presently under investigation. There was evidence from staff training records that staff had received appropriate training in adult protection issues. Since April 2006, there had been two allegations of abuse made by people who live in the service. These allegations were recorded and investigated internally on the advise of adult protection team in Doncaster. One was an allegation about staff misconduct, of verbal and physical abuse and the other was an allegation of assault by another service user. They were both reported to CSCI and adult protection team in Doncaster and both went through adult protection procedures and were upheld. The service was asked to investigate both of the allegations themselves and report back to adult protection. There was written evidence to show that some action has been taken to address both of the issues and
49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 18 further protect the individuals concerned including devising risk assessments, offering psychological support and carrying out disciplinary action against staff and then offering them further training and supervision. Another allegation of staff misconduct was reported verbally to the inspector but had not been reported to CSCI at the time of the inspection. The member of staff had been suspended pending an investigation. This information was subsequently received soon after the inspection. 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable and safe environment, which was very clean, it was decorated in an informal, cosy and age appropriate manner, which took in to account peoples complex needs. EVIDENCE: A tour of the building was completed with a staff and two service users showed the inspector their bedrooms. The home was registered in July 2003 and still continues to maintain a high standard of furnishings and fittings. All accommodation is single bedroom en – suite accommodation, and in addition to having all en–suite facilities, there is also an additional bathroom and WC and a separate WC. All of the bedrooms were individually personalised and well decorated. 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 20 There was a planned maintenance and renewal programme in place to ensure the home was well maintained and safe for the people who live there. Staff were aware of the dangers of being next to a busy main road, and therefore people are asked to leave the building by the back door. Further additional security measures including locks have been installed on one of the front gates to safeguard the welfare of all people who live at the home. There is a washing machine in the utility room, and the home has a policy and procedure on the control of infection to ensure that the risk of cross infection is minimised. Staff said they had received infection control training. The use and storage of chemicals is satisfactory, and the home was clean and hygienic for the benefit of all who lived and worked there. 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. Overall people were supported by committed and competent staff, however, more staff need to gain the NVQ 2 care awards to ensure that people are supported by appropriately trained and assessed staff. The recruitment policy and procedures protected the people who used the service. Individual staff were offered appropriate specialist and mandatory training at the required frequencies to ensure they remained up to date with good practice issues. EVIDENCE: The manager said that only 18 of the care staff had gained the NVQ2 care award and this should have been up to 50 by the end of 2005. She went on to say that more staff have just been signed up to complete the NVQ award. Three recruitment files were checked and they all contained relevant information including application forms, references and CRB checks, however, there were some issues with the CRB information which will need to be
49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 22 addressed, one file did not indicate if the CRB had been carried out at the enhanced level and this was checked and verified by the manager at the time of the inspection and the records were then amended. The other issue was that the records did not state whether the CRB’s were clear or not and if not whether any kind of risk assessment had been carried out and this will need to be included in the files to protect people who live in the home. Three staff training files were checked and showed evidence that they had all received mandatory training Re: fire safety, moving and handling, food hygiene, infection control and first aid. One of these people were due to have most of this training updated in April 2007. Other training that had been offered to staff included adult protection training, valuing people and DAPPA training to support staff in working with people with complex needs. 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a well managed home. The service users views are taken in to consideration when development of the service is considered, but this is done in an informal manner, therefore it was difficult to evidence the quality assurance system. The people who live at the home are protected by robust health and safety policies and practices. EVIDENCE: The manager of the service has only been in post for a short time at the time of the inspection and had not yet applied to CSCI to become the registered manager; this will need to be done as soon as possible. It was clear from speaking to people who use the service, staff and other managers that the manager is a very well liked and respected person who is seen as fair and an advocate for people who use the service. She holds numerous qualifications,
49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 24 including NVQ2/3/4 care awards, certificate in supervisory management and the registered managers award. She is also a qualified NVQ assessor and has worked in this field for many years. There was some evidence that service users views are sought about the service in an informal manner on a daily basis, at their care plan reviews and at their placement reviews, however, the inspector was told there was no other quality assurance system in place for reviewing and improving the service at regular intervals, which can be made in to a report which available to service users and the CSCI and this will need to be developed in order to ensure the people who live at the home are confident their views underpin all developments by the service. The manager did have copies of the Regulation 26 reports, which are sent to CSCI on a regular basis but these are not provided to people who use the service. Health and safety within the service is taken seriously and there were policies and procedures in place to protect service users and the staff team. Three staff training records were checked and showed that they had received training in all aspects of safe working practices, including moving and handling, fire safety, first aid, and food hygiene, and staff are aware of infection control procedures that protects the safety of the people they support. The fire and gas servicing records were checked and found to be up to date, and the electrical wiring was checked and had been last carried out in January 2007 ensuring a safe environment for all people accommodated. The accident book was checked and contained appropriate up to date details of the occurrence of accidents and the public liability insurance certificate was up to date and expires at the end of January 2008. 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 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 3 x 3 X 2 X X 3 x 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes. 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 Requirement The registered person must ensure that the home has an appropriate and up to date Service User Guide. (requirement carried forward as not met from 31/12/05) The registered person must ensure that resident’s views are obtained and included in the service user guide. (requirement carried forward as not met from 31/12/05) Timescale for action 30/06/07 2. YA39 24 30/09/07 3. YA39 24 A quality assurance system, which, is based on seeking the views of service users, must be devised and this information published for the service users and their representatives in order be sure their views are taken in to consideration when developments are made in the service. 30/09/07 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 27 4. YA6 15 Service users individual plans 30/09/07 must contain details of how the staff are to support the individual service users to meet their needs. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The service users should be supported to devise person centred planning models of care plans as advocated in Valuing People, a strategy for learning disability for the 21st century. This will ensure their needs and wishes can be met in the way they and their representatives prefer. The service users should be supported to devise health action plans as advocated in Valuing People, a strategy for learning disability for the 21st century. This will ensure their health care needs are identified and reviewed in a robust manner. The registered person must ensure that 50 of care staff achieve a qualification at NVQ Level 2 by 2005, and 80 achieve NVQ Level 3 when working with service users aged 16 and 17. 2 YA19 3 YA32 49 King Street DS0000044366.V320001.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 49 King Street DS0000044366.V320001.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!
